Police Complaints Authority

Review of shootings by police in England and Wales from 1998 to 2001

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Review of shootings by police in England and Wales from 1998 to 2001

Report to the Secretary of State for the Home Department by the Police Complaints Authority pursuant to S. 79(1) of the Police Act 1996

Ordered by The House of Commons to be printed 30 January 2003

HC.313 Sir,

I have the honour to submit to you, in accordance with Section 79(1) of the Police Act 1996, a report requested by the Secretary of State into shootings by police in England and Wales from 1998 to 2001.

I am, Sir

Your obedient servant

Sir Alistair Graham Chairman, Police Complaints Authority

The Rt Hon David Blunkett, MP Secretary of State for the Home Department Preface

This review was prepared by Alan Bailey1 (External Consultant to the PCA on the police use of ), Dr David Best (Head of Research at the PCA) and the two Deputy Chairmen of the PCA, Ian Bynoe and Wendy Towers. The constitution of the group was selected to ensure that expertise and experience in police use of firearms was combined with research expertise and with the managerial and policy perspective of the PCA membership. Additional input on individual cases and matters of technical expertise were obtained as required in the process of conducting the review.

The authors would like to thank all those who contributed to the review by participating in interviews, providing written submissions, reviewing and editing earlier drafts of the report and by providing expert input around particular issues that arose during its preparation. Our thanks must also go to Her Majesty’s of Constabulary, the Association of Chief Police Officers and Professor Geoffrey Alpert, University of South Carolina, for commenting on a number of drafts of the report.

The review has used the available evidence to identify key issues for the police service from both individual cases and from a synthesis of the 24 cases included in the review. The methods have been mutually generative in that the questions addressed using statistical analyses have been based on simple data frequencies and the questions elicited from the expert analysis of cases. Although the methods are statistically sound, they are based on restricted data, and we see this work as the first stage in developing a comprehensive picture – a picture which will require, as we have recommended, a commitment to data collection and analysis from the police forces to this work. In particular, it is critical that firearms units collate more satisfactory information on incidents in which shots are not fired as a comparison group for contextualising the data collated in the review.

The conclusions reached are extremely positive and would indicate that firearms units in England and Wales are highly professional. On the other hand, for lessons to be learned in a police service that is critical and reflective, it is essential that the review process is ongoing and based on sound empirical foundations. The recommendations from the Burrows review have not been implemented according to systematic criteria across forces and it is this process of review, revision and evaluation that is at the heart of the recommendations made in the current report.

1 Alan Bailey was a for 30 years. During this time, he performed the roles of Authorised Firearms Officer, Tactical Advisor and Silver Firearms Commander. From 1998 until 2001 he was Head of the National Operations Faculty at Bramshill Police Staff College. He holds academic degrees in the management of firearms operations and has given expert witness evidence on firearms practice in criminal trials.

Police Complaints Authority 1 Contents

Preface 1

List of Tables 4

Glossary 5

Executive summary 6

Chapter One: Introduction 12

Chapter Two: Aims, rationale and method 20

Chapter Three: Family and key informant interviews 24

Chapter Four: Summaries of the cases included in the review 29

Chapter Five: Quantitative analysis of the 24 cases included in the review 56

Chapter Six: Learning the lessons 69 A. Management of the incident 73 B. Characteristics of the individuals shot 98 C. Post-incident issues 101

Chapter Seven: Conclusion 114

References 115

Appendix 1: Review recommendations 117

Appendix 2: Standardised pro forma used for analysis of PCA case files 124

Police Complaints Authority 3 List of tables

Table 1: Classification of incidents in the Burrows Report 13

Table 2: Relationship between deployments, operations and police discharge of weapons between 1997 and 2001 21

Table 3: Summary of the cases involved in the review 58

Table 4: Possible explanatory factors in each of the 20 cases for which reports were available 59

Table 5: Analysis of shootings within the review classified as ‘rational’ 61

Table 6: Analysis of shootings within the review classified as ‘irrational’ 62

Table 7: Summary of the criminal and disciplinary proceedings and inquest verdicts from each of the review cases 67

Table 8: Number of incidents and number of authorised firearms officers in England and Wales, and in the MPS, 1997–2001 (Source – HMIC) 71

Table 9: Rates of shootings as a function of relevant demographic factors comparing the MPS and other forces in England and Wales 87

Table 10: Police shootings per 1,000 firearms operations in the MPS and other metropolitan forces 88

Table 11: Dates for the key events in the 20 cases in the review for which the investigation had been completed 102

4 Police Complaints Authority Glossary

ACC Assistant Chief

ACPO Association of Chief Police Officers

APA Association of Police Authorities

ARV

CPS Crown Prosecution Service

ECHR European Convention on Human Rights

ECtHR European Court of Human Rights

FLO Family Liaison Officer

HMIC Her Majesty’s Inspectors of Constabulary

HRA Human Rights Act 1998

IO Investigating Officer

IPCC Independent Police Complaints Commission

MPS Service

NGO Non Governmental Organisation

NLEMF National Law Enforcement Memorial Fund

PCA Police Complaints Authority

PCCG Police Community Consultative Group

PNC Police National Computer

Principal officers Those officers who have fired or whose actions have altered the course of events at the scene of the shooting incident

PSDB Police Scientific Development Branch

PTSD Post-Traumatic Stress Disorder

SIO Senior Investigating Officer

SO19 Metropolitan Police Service Tactical Firearms Department

Police Complaints Authority 5 Executive summary

Background and Method This review was commissioned by the Rt Hon. John Denham MP, Minister of State at the under Section 79(1) of The Police Act 1996, with terms of reference requiring a review of: • The planning, control and conduct of operations; • The way in which the concerns of the bereaved families were addressed, and how they were kept informed of the progress of the investigation; and • The training and skill needs of the police officers involved in such operations, particularly at command level.

The report follows a previous (unpublished) report examining the discharge of firearms by police between 1991 and 1993, known as the “Burrows Report” (ACPO in consultation with the PCA), which reviewed a total of 23 incidents referred to the PCA (eight of which were fatal). Seven of the incidents resulted from robberies, nine from domestic disputes and seven from ‘other incidents’, which did not lend to a natural classification. In three of the robberies, at least two of the domestic incidents and at least one of the other incidents, shots were fired by the suspect. Burrows concluded that the number of instances that could be regarded as ‘suicides by cop’ and the prevalence of alcohol, drugs and mental health factors among those shot were major concerns for the police.

The more recent policy context for the review is the ACPO Manual of Guidance on Police Use of Firearms (January 2001), which takes into account Article 2 of the ECHR. This states that: “everyone’s right to life shall be protected by law”. Section 2.1 of the Manual provides that: “In deciding whether the action was ‘necessary in a democratic society’ it will be necessary to consider whether the action:

a. fulfilled a pressing social need, and b. pursued a legitimate aim, and c. there was a reasonable relationship of proportionality between the means employed and the aim pursued.”

6 Police Complaints Authority The current review spans the period before and immediately after the introduction of the Act and seeks to address the broader question of what lessons have been learned, both since the Burrows Report and across the period under review. The review will outline each of the 24 firearms incidents, 11 fatal, referred to the PCA for supervision and accepted by the Authority between January 1998 and November 2001 in an attempt to address this question and those posed by the terms of reference outlined above. The methodology employed involved a combination of documentary analysis of the PCA case files supplemented by expert analysis, key informant interviews and information from some of the families of the 11 individuals who died as a result of the police shootings during this period.

Results The forces involved in the cases were: • Metropolitan Police Service (11 cases); • Merseyside (3 cases); • Devon and Cornwall (2 cases); and • West Yorkshire, Bedfordshire, Surrey, Gwent, West Midlands, West Mercia, Derbyshire, Sussex (1 case each).

Six of the incidents occurred in 1998, seven in 1999, seven in 2000 and four in 2001. Using the classification employed in the Burrows Report, four of the incidents were ‘robberies’, 10 were ‘domestic incidents’ and 10 ‘other’ incidents. Four of the 24 were ‘pre-planned’ while 20 were spontaneous incidents. The main characteristics of the 20 cases in which the investigations were complete or almost complete by the time of writing are shown in the table overleaf:

Police Complaints Authority 7 ES Table 1: Characteristics of the shootings for the 20 incidents that had completed investigations at the time of writing of the report

bery pon type a

Date Shots/hits Age Rob Domesticissues Mental health Intoxicated History ofsubstance useWe real? 1998 1/1 39 – ––––None – 1998 1/1 32 – – X X – Imitation 1998 1/1 51 – XXXXKnife – 1998 1/1 28 – – X X – Pistol Imitation 1998 6/1 30 – – X – X None – 1998 3/1 33 – X – – – Yes 1999 4/2 18 – – X X X Rifle Imitation 1999 2/1 20 – XXX–Air-rifle Yes 1999 1/1 47 – XXXXAir-pistol Yes 1999 2/1 36 X –––XShotgun Yes 1999 2/2 46 – – – X – None – 1999 1/1 18 X –––XNone – 1999 1/1 34 – – X X X Pistol Imitation 2000 1/1 19 Kidnap ––––None – 2000 7/2 46 – X – X – Pistol Imitation 2000 2/2 26 – – X – – Axe – 2000 3/2 30 – XXXXAir-Rifle Yes 2000 3/1 19 X –––XPistol Imitation 2000 1/1 19 – X X – X Corkscrew/knife 2000 2/1 28 X ––––Shotgun Imitation

In total, there were 55 shots fired in the 24 incidents (an average of 2.3 per incident), of which 32 hit individuals (or 58.2%). In one incident six of the shots were aimed at and hit adog. Here it was a ricochet that struck the individual. It is worth noting that in the 11 fatal shootings, a lower average number of shots were fired (1.9) but with a higher hit rate (76.1%) – in six of 11 a single shot was fired. The summary data would suggest that: • 11/24 of those shot had been drinking on the day of the shooting (six fatal shootings); • 10/24 were involved in the use of illicit drugs (with possible drug issues in two further cases); • There was evidence of the person shot being affected by mental health problems in 11/24 cases (with three more possible cases involving mental health issues); • Suggestions of self-harm or suicidal intentions arose in 12/24 cases (including seven of the 11 fatalities); and • Only 4/24 cases involved armed robbery and one other a suspected kidnapping and none of these cases resulted in a fatality.

8 Police Complaints Authority Only one of the individuals shot discharged their ‘weapon’ in the presence of armed police (although this was aimed at a door) while four did not have a weapon (real or imitation) at the time of the shooting. Of the 20 who had something that resembled a weapon, one had two metal tubes in a plastic bag, one had a table leg wrapped in a bag and eight others had imitation guns (albeit one of these was capable of firing CS incapacitant canisters). Of the remainder, four had edged weapons (two knives, an axe and a sword respectively), and six had a shot-gun, air rifle or rifle. However, for all of the imitations, it would not have been possible for the officers to tell that they were not real at the time of the shooting.

In only two instances, one where a police officer was stabbed in the hand by a knife that was thrown and one where one of those shot physically assaulted his girlfriend with a knife and a corkscrew, did the use of the weapon by the suspect result in injury to another person. Three members of the public (two of whom were partners of the individuals shot) had been assaulted in the period immediately prior to the arrival at the scene of the firearms officers. Attempts at quantitative analysis were hampered by inconsistencies in reporting between forces and across time and this is an issue that should be rectified in future by the use of a standardised reporting form.

Family issues In the interviews conducted with family members assessing their perceptions of the incidents, the main concerns raised were that: • The police had fired too quickly, so depriving the family of the opportunity to intervene, and that the police tactics had been inappropriate; • There was a lack of co-ordination between the agencies involved (particularly between the police and mental health services) both before and after the shootings; • The investigating force was known to the officers involved, questioning their impartiality, which compounded family feelings of being marginalised in the investigations, not being kept informed and, on occasion, being treated unacceptably by the incident investigators; and • There were long delays in reaching decisions and in holding inquests, causing distress and uncertainty both to the officers and the families.

Key informant interviews A number of key informants who were involved either with vulnerable groups such as those with mental illness, with the development of police policy or with the investigation of police shootings were also contacted as part of the project. Among the main views expressed were: • concerns that forces did not learn the lessons, partly supported by the lack of evidence, in certain later cases, that operational behaviour had changed as a result of recommendations from earlier incidents; • concerns from the police staff associations and the families of people shot by the police over the quality of firearms training; and

Police Complaints Authority 9 • concerns about both the impartiality of CPS decision-making and the time taken by the CPS to reach decisions on criminal charges.

Implications While there are a number of detailed recommendations about both the police management of firearms incidents and the post-incident management, the main implications related to:

1. The failure to learn lessons (from incidents in other forces and particularly for the forces which had a significant number of such cases) necessitates more adequate measures for disseminating and implementing the recommendations from previous incidents (to be monitored by HMIC). This dissemination should be based on a stronger evidence base consisting of a programme of research work in this area. 2. While it is acknowledged that spontaneous incidents can be over in a matter of minutes, making planned responses difficult to manage, the number of spontaneous incidents that are completed before the command structure can be established indicates that the Gold, Silver and Bronze model is not helpful and should be supplemented by a more effective command system for such short, spontaneous incidents. 3. The failures of command and management, in a number of the cases included, suggests the need for an urgent review of the role of the Silver Commander in decision making, and may highlight training and selection issues for this group. 4. The large number of incidents that appear to have been ‘provoked’ shootings, in addition to the preponderance of intoxication, addiction and mental health factors in spontaneous incidents suggests that training and strategy for spontaneous firearms incidents needs to be focused to a far greater degree on the needs of such populations. Furthermore, tactics need to be developed for tackling a non-compliant individual in possession of a firearm who is not posing an immediate threat. 5. There is an urgent requirement for the development of a coherent strategy for the use of “less lethal” options including clearer evidence-based guidance on the use of general purpose or attack dogs, the circumstances and training needed for the use of negotiators and the role of unarmed officers. In addition, urgent answers are required concerning the effectiveness and applicability of alternative weapon systems such as guns, water cannon and electrical or mechanical incapacitation devices.

Conclusions The 24 shootings reviewed here cannot be neatly grouped together as a result of the marked variability in both incident evolution and outcomes. Conclusions are therefore necessarily tentative. For the pre-planned robbery operations, there is relatively little of contention in the planning of the operations. For the remainder, the factors requiring consideration are much more complex – in more than half (11/20), the individual who was shot appears to have had this as their objective, while at least two others had marked mental health problems and another five were intoxicated at the time of the shooting. This level of unpredictability makes the assumption of rational response invalid and makes attributing responsibility highly problematic. On this basis, we have applied a new

10 Police Complaints Authority categorisation system which distinguishes cases on the basis of the perceived “rationality” of the actions of the individual shot. Finally, in a small number, one must admit to the possibility that the individual was shot in error – certainly at least one accidental gun discharge and one person caught by a bullet splinter fall into this category.

There are a number of management, policy, tactical and training issues for the police forces and ACPO to address – some of which were also raised in the Burrows Report. There would appear to be significant problems with command and management of some incidents, and there are several incidents where the methods employed would suggest a lack of strategic thinking or planning by both experienced firearms officers and by their commanders. Similarly, the use of proactive methods designed to generate an expeditious and timely conclusion may result in an increased risk of weapon discharges that forces may have to consider in the light of human rights legislation.

This review has found many reasons to be encouraged by the current situation in England and Wales and the small number of weapons discharged during the period in relation to the total of armed deployments suggests that the overall picture is a positive one. The review has not identified any concerns about legal justification in more than a handful of cases2. However, the Right to Life principle now governing every aspect of the police use of firearms sets a demanding standard for the police service to meet which does not stop with the officer who pulls the . Heeding the lessons for police practice and organisation detailed in this report and implementing its recommendations may help to ensure that the standard is fully met in the future.

2Article 2 of the ECHR does not establish entirely new grounds to justify deprivation of life. It recognises the lawful use of legal force e.g. in reasonable self or third party defence, including where a police officer is honestly mistaken as to the threat posed by the person killed. When deciding whether a fatal shooting is “absolutely necessary”, the following will still have to be considered: the firer’s purpose; the threat posed by the actions of the person shot; and the risk that the force used will cause loss of life.

Police Complaints Authority 11 Chapter One: Introduction

This report is based on the findings of a review commissioned by The Rt Hon. John Denham MP, Minister of State, Home Office, under Section 79(1) of The Police Act 1996. The terms of reference announced in Parliament on 20th November 2001 were:

The review will consider what lessons can be learnt from the investigations into police shootings, which have resulted in death or injury, since January 1998.

In particular the review will look at: • The planning, control and conduct of operations; • The way in which the concerns of the bereaved families were addressed, and how they were kept informed of the progress of the investigation; and • The training and skill needs of the police officers involved in such operations, particularly at command level.

Section 79(1) of The Police Act 1996 allows the to call for a report from the PCA on issues of concern. Although each incident in which a member of the public is shot by an armed police officer is the subject of a detailed and thorough investigation, systematic analysis over time and across incidents has been limited. This introduction will outline briefly the research and policy history of the police use of firearms in the UK and the legal context that has altered this framework, particularly since the introduction into English law of the ECHR.

The introduction covers the major pieces of work carried out in this area that are of direct relevance to the current review, and fall into four main sections: • ‘The Burrows Report’ • The developing social and legal context • ACPO Manual of Guidance • Recent international research evidence

The Burrows Report There has been one important UK shootings review prior to this one – Review of incidents involving the discharge of firearms by police, 1991-1993,“The Burrows Report” produced by ACPO in consultation with the PCA.

12 Police Complaints Authority This study reviewed a total of 23 incidents referred to the PCA (eight of which were fatal) – seven resulting from robberies, nine from domestic disputes and seven which did not lend themselves to a natural classification. The main source of data was the PCA files supplemented by key informant interviews.

Live fire weapons were used in six of the seven robberies where an individual was shot, in all nine of the domestic incidents and in three of the seven ‘other’ incidents. Of the non-firing weapons, four involved imitations and one an edged weapon. In three of the robberies, at least two of the domestic incidents and at least one of the other incidents, shots were fired by the suspect. It is immediately significant to note that this did not happen in any of the completed cases in the current review – no live weapon was fired at an officer during any of the incidents. Similarly, three officers and one civilian were injured during the robbery incidents. In the domestic incidents, one civilian was injured and another seriously injured prior to the arrival of the firearms officers and a police officer was shot while trying to draw his weapon but there is no report of the number of injuries sustained by non- suspects during the other incidents.

The breakdown of discharges in the incidents were as follows:

Table 1: Classification of incidents in the Burrows Report

Robbery Domestic Other Total (n=7) (n=9) (n=7) (n=23) Police rounds fired 41 31 28 100 Number of hits 15 16 13 44 Number of fatal hits 1 4 3 8 Drugs/alcohol – 6 3 9 ‘Disturbed’ – 4 6 10 ‘Provoked’ – 6 3 9

Among the domestic disputes, Burrows pointed out two significant issues – the number of instances that could be regarded as ‘suicides by cop’ and the relevance of alcohol, drugs and mental health issues among those shot. Burrows argued that six out of nine ‘domestic’ cases involved drug or alcohol issues, four out of nine were among ‘disturbed’ individuals, and he classed six out of nine as provoked shootings. Similarly, in the ‘other’ incidents, three were described as involving drugs or alcohol, six as involving ‘disturbed’ individuals and three as being ‘provoked’.

Burrows pointed out that it was relatively rare for a complex command structure to be developed in time, and when established, this was only effective in about half the cases. Burrows also commented on the problems involved with the deployment of dogs and with the blurring of roles when several different disciplines were involved. He also expressed concern about the adequacy of communication and the adequacy of the rationale for some

Police Complaints Authority 13 operations. Burrows also reported on the relatively low ‘hit rate’ with 56% of the rounds fired missing their intended targets, leading to the suggestion that there should be a review of training techniques for firearms officers.

In discussing post incident investigation, Burrows commented that “the style and format of the reports varied considerably and it was often difficult to obtain an early grasp of how the events arose”3.

Burrows also recommended that: • The Gold, Silver and Bronze system of command and control of firearms incidents should be re-examined; • The purpose and rationale behind all firearms operations should be clearly documented within a policy log in which key decisions and policy directives are recorded; • Tactical options should be listed and the reasons for discounting or selecting them should be documented; and • Training for firearms officers should continue to emphasise the use of cover and to distinguish between ‘cover from view’ and ‘substantial ballistic cover’.

It is beyond the scope of the current review to comment on the recommendations arising from the Burrows Report. However, it is regrettable that there is no formal mechanism for assessing their implementation and many of the findings presented below would suggest that implementation has not been universal.

The developing social and legal context The legislative framework for analysis changed during the review period as a consequence of the introduction into law of the HRA 1998. This incorporated directly into UK law from the 2nd of October 2000 the provisions of Articles 2 to 18 excluding 13 and 15 of the ECHR. According to Article 2 on “Right to Life”, “Everyone’s right to life shall be protected by law”. The Article continues “Deprivation of life shall not be regarded as inflicted in contravention of this Article when it results from the use of force which is no more than absolutely necessary:

a. in defence of any person from unlawful violence b. in order to effect a lawful arrest or to prevent the escape of a person lawfully detained c. in action lawfully taken for the purpose of quelling a riot or insurrection.”

3 Among the core recommendations made in the Burrows Report were that: “Police firearms officers receive specific training in dealing with a wide range of incidents. This should include awareness training in respect of dealing with the mentally ill and those under the influence of alcohol and drugs, basic skills in communicating and negotiating with special population groups and it is recommended that the assistance of professionals who work with these groups be obtained in training both firearms officers and negotiators” (p26).

14 Police Complaints Authority After incorporation, legislation (insofar as this was possible) and the common law would have to be interpreted so as to give effect to these principles. Article 2 clearly permits the taking of life only where absolutely necessary. The new standard has great significance for the planning and command of firearms operations, not just for the officers using the lethal firearms. The change in the law prompted a substantial revision of the ACPO Manual of Guidance.

ACPO Manual of Guidance on Police Use of Firearms (January 2001) The Manual acknowledges the Act explicitly in its assertion that “The responsibility of the police service (and other public services) is not only to comply with the Articles but also extends to taking positive action to protect the rights and freedoms they outline”. Section 2.1 of the Manual goes on to assert that: “In deciding whether the action was ‘necessary in a democratic society’ it will be necessary to consider whether the action:

a. fulfilled a pressing social need, and b. pursued a legitimate aim, and c. there was a reasonable relationship of proportionality between the means employed and the aim pursued.”

The Manual quotes the European Court of Human Rights’ assertion in McCann v United Kingdom4 that “in keeping with the importance of this provision [the right to life] in a democratic society the court must, in making its assessment, subject deprivation of life to the most careful scrutiny …. Taking into account not only the actions of the agents of the State who actually administer the force but also all the surrounding circumstances including such matters as the planning and control of the actions under examination.”5

Chapter 4 of the Manual deals with issues of command. It starts with the assertion that “the possibility of potentially lethal force being used by the Police Service places an obligation on them to ensure that an operation is controlled through effective Command”6. According to the command structure set out, the Gold Commander has responsibility for strategy and “the overall intention to combine resources towards managing and resolving an event or incident”; the Silver Commander is responsible for tactics, specifically “the way that resources are used to achieve the strategic intentions within the range of approved tactical options”, and has the communication responsibility for liaising with both Bronze and Gold Commanders; and the Bronze Commander is responsible for the implementation of the tactical plan and “organises the groups of resources to carry out the tactical plan”. All three levels of the command structure are responsible for the accurate recording of decisions taken to ensure that a clear audit trail exists.

4 (1996) 15 EHRR 97 5 3.4.4 6 4.1.1

Police Complaints Authority 15 Another issue, which has provoked considerable public debate, has been around the body areas targeted by the police in the training and instruction of firearms officers. According to Chapter 5 of the ACPO Firearms Manual, police officers “shoot to stop an immediate threat to life” and that they should do so by aiming to hit the central nervous system, which should be “effective in achieving rapid incapacitation”, as shots striking other parts of the body cannot be relied upon to achieve this effect. The Manual further clarifies that police officers are “therefore normally trained to fire at the largest part of the target they can see which in most cases will be the central body mass” (ACPO Firearms Manual, Chapter 5). In terms of the number of shots discharged, the Manual requires that after each shot, the officer should reassess the need for further action. In sum, the aim is to fire as infrequently as is possible, but that when shots are fired they should be aimed at the central body mass in order to achieve incapacitation of the suspect.

Recent international research on police use of firearms There does not appear to be a significant body of empirical evidence on the police use of firearms, with particularly little evidence available about the police use of firearms in the UK. What is presented below is a summary of the main points from the international literature, which relies primarily on evidence from North America. Constitutional, legal and cultural differences inevitably restrict the applicability of such findings and require that they are interpreted with considerable caution. However, in the absence of appropriate UK evidence, this body of evidence may provide some useful indicators of some of the main areas of evidence about the police use of firearms.

1. Prevalence of police shootings An overview of “Police Vehicles and Firearms: Instruments of Deadly Force” by Alpert and Fridell (1992) examined issues around prevalence and patterns in American cities. Sherman et al (1986) reported a significant drop in killings by law enforcement officers in big cities in the US from 353 in 1971 to 172 in 1984. There was also a 65% drop in the number of police officers killed in the line of duty in this period. They also reported that, in the 50 largest US cities in 1984, there were approximately 1,229 “deadly force incidents” (ie shots were fired) resulting in 418 woundings and 172 deaths (a hit rate of 48%).

According to the NLEMF, there were an average of 146 on-duty police fatalities per year in the United States between 1990 and 1993. Of the 151 US police officers who died in 1993, 75 were killed by an assailant using a firearm, 23 others were killed by other means. The remaining 53 officers died from accidental causes while on duty.

2. The circumstances of police shootings In terms of hit rates, Geller and Karales (1981) reported that 18% of the police shots fired in Chicago between 1974-78 hit a citizen, of whom 25% were killed, while Horvath (1987), in Michigan, reported that 32% of police shots hit a citizen, of whom 35% were fatally wounded.

16 Police Complaints Authority Fyfe (1978) in a study of New York shootings reported that 37% of police shootings were in connection with robberies while the New York State Commission (1987) reported that 46% of deadly police force occurred on streets, highways or alleys, 10% in multi-family dwellings, and 8% in stairwells or lifts.

3. Theoretical models for the likelihood of police shooting Kania and Mackey (1977) are among researchers who have reported strong correlations between justifiable homicides by police and both the public homicide rate and police exposure to violent crime. Similarly, both Fyfe (1980) and Kania and Mackey (1977) attributed the relationship between violent crime and police shootings to perceived danger on the part of police. That is, they believed that the high rate of violence in a particular geographic area leads police to perceive the environment as dangerous and makes them more inclined to use deadly force. It is important to point out, however, the contextual difference in the UK where a strategic decision is required to deploy an armed officer, which may provide an extra level of public protection, compared with countries in which police forces are routinely armed.

The issue of racial disproportionality has also arisen in the context of explaining the patterning of police shootings and the theoretical models employed for this. While Fyfe (1980) has suggested that those disproportionately involved in crime are more likely to be shot by the police, Goldkamp (1976) presented the alternative view, which has been referred to as ‘quasi-labelling’. According to this view, the disproportionate rate of shootings of ethnic minorities arises from a differential policing approach for such groups which is based on a police belief that they engage in greater levels of criminality.

MacDonald et al (2001) combine these views in what has been referred to as the ‘danger- perception theory’ according to which officers are more likely to use deadly force during periods in which (or in places where) they encounter greater levels of violence or view their job as particularly hazardous. In support of this ‘ratio threat’ theory, MacDonald and colleagues hypothesised that there would be a stronger link between police killings of civilians and robbery-related homicides than with love triangle killings, a finding they verified in an analysis of shootings between 1976 and 1996.

4. Administrative policy and the rate of police shooting In an analysis of 982 police shootings in Philadelphia between 1970 and 1992, White (1999) emphasised the importance of discretion control mechanisms in police policies on the use of firearms, particularly around the policies and ethnicity of the mayor responsible for each police force. The abolition of a restrictive administrative policy in 1974 was associated with a significant increase in shootings. This led White to conclude that while administrative policies can be effective in restricting police shootings, the extent of this effect will be contingent on the personal philosophies of the police chief and the resultant organisational culture. While US mayors are elected to office, the most relevant comparison may be around how the head of a police force can, both through formal policy and daily practice, shape the philosophy and ethos of a force, which in turn may impact on officers’ willingness to discharge their firearms.

Police Complaints Authority 17 The impact of administrative policy and environmental factors was also identified by Jacobs and O’Brien (1998). Their analysis of police killings in 170 US cities demonstrated that the use of lethal force by police officers was strongly predicted by murder rates, population density and divorce rates. Once these factors had been taken into account, other environmental factors, such as economic inequality, were relatively poorly related to the police use of firearms. However, with regard to ethnicity, they reported that police killings were more likely where economic differences between blacks and whites are most pronounced. They argued that racial inequality accounted not only for a proportion of the total rate of police killings but also for the proportion of black people killed by the police in these communities.

5. Who shoots and who do they shoot in police shootings? Aadland (1981) found an inverse relationship between shooting and both the age and law enforcement experience of the officer. With regard to the characteristics of the individual shot, Milton et al (1977) found that black people represented 39% of the population in seven US cities and were the victims of police shootings in 79% of incidents. Meyer (1980) found that the circumstances surrounding the shooting of black people differed from Hispanic and white people. On examining the suspects’ actions prior to the shootings, 15% of the shooting of black people compared with 9% of Anglo and Hispanic shootings were preceded by the suspect disobeying the officers’ order to halt.

From studies using ‘shoot-non-shoot’ methodologies (comparing discharges with similar incidents where guns were not discharged), Fridell and Binder (1988) argued that encounters characterised by ambiguity or surprise are more likely to result in the use of deadly force. This was partly based on the fact that more of the non-shooters knew their opponents, and they were more often able to make judgements about the emotional states of the suspects. They also reported that a larger percentage of shooters (44%) reported that the verbal exchange made the suspect angrier than in non-shooting incidents (28%).

The impact that discharging their weapon has on police officers has been examined by Parent and Verdun-Jones (1999). They interviewed officers involved in 16 lethal shootings who reported that, during the incident, they experienced perceptual alterations, including tunnel vision, altered perceptions of time and auditory distortions. However, following the incidents more severe symptoms were reported. These included guilt, nightmares, flashbacks, and the stress that may result from intense (and often inaccurate) media scrutiny. The long-term effects included termination of long-term relationships and the development of drug and alcohol problems in a number of the officers involved.

18 Police Complaints Authority 6. Conclusion and overview Despite what is summarised above, Alpert and Fridell (1992) have argued convincingly that the lack of evidence in this area has impeded the development of effective, evidence-based policy, a concern that would apply equally to the UK context.

Perhaps the international study that bears most direct comparison with the current work was carried out by Parent and Verdun-Jones (1999) who investigated 25 police shootings between 1980 and 1994 in British Columbia. They reported that while almost half of the fatal shootings involved persons with mental disorders or irrational behaviour on the part of the suspect, six involved the prior use of alcohol or drugs by the suspect, and eight shootings are described as ‘victim-precipitated’.

This last group of individuals are characterised as having a “general sense of depression, hopelessness and low esteem” which has led them to engage “in a calculated life- threatening criminal incident in order to force a police officer or another individual to kill him or her”. Parent and Verdun-Jones concluded that “police officers required training that will allow them to identify suicidal cues when confronting an individual who is armed and dangerous. By identifying these suicidal cues, the police officer may be able to assess which strategic option is appropriate for the circumstances”. They argued that the most effective strategy may be for the officers physically to distance themselves from victims who are bent on forcing a victim-precipitated homicide.

Police Complaints Authority 19 Chapter Two: Aims, rationale and method

The synopsis of policy and research evidence presented above formed the context for developing the review methodology. The review has also considered the implications of the United Nations Basic Principles on the Use of Force and Firearms by Law Enforcement Officials7,8.The aim of the review was to comply with the terms of reference and to inform future decision-making together with the investigation of police use of firearms and its impact on those affected. The methods outlined below were constructed to address the terms of reference by examining the command of the reviewed incidents, the experiences of the families and the concerns they had, and the identification of training needs for the officers.

The evidential component of the review will involve an outline of each of the 24 firearms incidents where the investigation was referred to the PCA and accepted for supervision between January 1998 and November 2001, followed by a quantitative analysis of these 24 incidents. This will provide the basis for learning points identified either by the SIO for specific incidents or subsequently identified by the PCA expert firearms adviser. The case review will be considered in the light of evidence derived from key informant interviews and from interviews with and correspondence obtained from the relatives of those fatally shot who were willing to participate in the review.

The review will synthesise the evidence obtained from published literature and policy, with the information from key informants and from the expert review of the 24 cases as the basis for the conclusions and recommendations reached. The recommendations are designed to increase compliance with the ECHR, improve the effectiveness of police firearms operations and their subsequent investigation and post-incident management. Whilst a tiny minority of all firearms incidents result in the discharge of a police firearm, the review attempts to reduce further this number by scrutinising policy and practice and, where such incidents do occur, to ensure that the investigation is as thorough, as timely and as sensitive as is possible under the circumstances.

7 1990 8With the creation in 2004 of the IPCC, one of the major concerns expressed in the case of Shanaghan v UK, (37715/97) The Times, March 17 2000 ECtHR inter alia concerning the use of investigators independent from the will be addressed.

20 Police Complaints Authority CONTEXT In terms of the number of incidents dealt with each year, the police use of firearms is a generally successful policing strategy. As illustrated in the table below (based on HMIC data), the total number of shots fired and the number of armed incidents which result in a discharge of a police weapon, is a tiny fraction of both the number of operations for which firearms are issued and the number of ARV operations:

Table 2: Relationship between deployments, operations and police discharge of weapons between 1997 and 2001 (Source: HMIC)

Year Number of Number of Number of Shots fired as operations in which ARV operations shots fired a proportion firearms issued at people of firearms operations 97/98 11,842 7,510 3 0.03% 98/99 11,005 7,906 13 0.11% 99/00 10,915 8,276 10 0.09% 00/01 11,109 8,179 18 0.16%

As can be seen from the above table, in each of the relevant years, around every thousandth incident which involves the deployment of firearms to police officers in England and Wales results in a weapon being discharged. This would indicate that the cases examined in the study are exceptional and unrepresentative. This does not, however, mean that they should not be treated as critical events that are likely to provide suitable lessons. It does, however, preclude any sensible comparison of the incidents in which shots were fired and those in which this did not take place.

The fact that the report focuses on lessons to be learned from the 24 cases might imply these incidents comprise a catalogue of failure. However, the majority of police actions in the incidents examined do not raise any issues and so are not commented on. As the review covers a period of four years, many of the recommendations made by the SIOs highlight issues that have already been addressed. In addition, some of the themes across practice issues have not been brought together in this way. It is the “bigger picture” provided by the overview of the cases that results in many of the conclusions and recommendations presented here. Only when the cases are put together do issues for learning emerge.

The British tradition It should be noted that one aspect of the British tradition of unarmed police is that all the officers who do carry firearms volunteer to do so. This occurs within a national strategy of training only enough firearms officers to meet operational need. As a result, only a small fraction of officers from each force are authorised to carry firearms.

Police Complaints Authority 21 The peaceful resolution of an armed incident sometimes relies on actions taken during its early stages by unarmed officers who often display considerable bravery to protect the public from what is perceived to be a threat to life. The combination of unarmed officers immediately responding, with armed officers supporting and taking over provides the public with considerable protection while maintaining the tradition of an unarmed police service. This has continued against the background of both terrorist threat and an increase in the illegal use of firearms and other weapons.

The weapons that are used by the police forces in England and Wales, in the cases reviewed, were all self-loading (the mechanism re-loads the weapon although the trigger must be depressed on each occasion a shot is fired) or single shot versions of carbines (small rifles). The carbines are manufactured according to other specifications which can permit burst fire or fully automatic, although they were never used in this way in the cases reviewed.

METHOD The terms of reference provided the exclusion criteria that identified the sample of 24 cases. Cases were excluded if:

1. shots were fired by police (including those that were accidental) but did not result in death or injury; or 2. the incident was classified as a suicide while under armed police containment.

In other words, all cases where a discharge from a police weapon resulted in death or injury to a member of the public in the target period were included. The exclusion of cases where a police officer fired but did not hit a suspect, at any point, during the incident will increase the apparent ‘hit rate’ for police discharges as these excluded cases were included in previous research (such as the Burrows Report). Suicides while under armed containment, while outside the terms of reference of this review, remain a significant and problematic issue which would benefit from a separate assessment, and may be similar in terms of suspect characteristics and incident management to provoked shootings.

Source Material The investigations of each of the incidents included in the current review have been supervised by the PCA, the independent body with statutory responsibility to oversee inquiries into the most serious complaints against police.

The investigation, headed by a SIO, results in a report of the evidence which, in addition to a file of documents and correspondence, constitutes the basis of the PCA case file. It is scrutiny of these 24 PCA files that forms the central component of the report. For four of the 24 cases included in the report, the investigation had not been completed at the time of writing.

22 Police Complaints Authority This primary source of data was supplemented by two additional categories of original information gathered for the review:

1. Interviews with families of the victims of fatal police shootings: the families or their legal representatives of the eleven individuals fatally wounded in police shootings were contacted to invite their participation by written submission or face-to-face interview. Three families agreed to participate in interviews, one participated by e-mail and another through their legal representatives. Six families did not participate in the review. 2. Key informant interviews: a snowball method was used to identify individuals, groups or organisations believed to be key stakeholders around particular incidents or who had general policy concerns about police use of firearms. This means that initial contacts were asked to identify others who they believed would have significant views to ensure that a comprehensive sample was obtained. A total of 30 contributions were made by key informants: nine from NGOs or individuals involved in incidents; nine from police forces in which shootings had occurred; eight from SIOs who had investigated cases; and four from PCCGs. This represents 70% of all the requests for information that were sent out.

File Analysis Interrogation of the files was structured via a mixed methodology combining quantitative data with qualitative information. Expert analysis was used to identify issues on operational or tactical features which breach guidance or raise questions about appropriateness in the circumstances in which particular approaches were used.

The method is designed to provide a simultaneous analysis of the patterns that can only be identified from cross-incident study together with identification of unique significant characteristics of particular incidents. Thus, while there are a number of individual incidents that suggest important learning points, the main advantage of the review approach is the identification of themes that occur in several incidents or which have general relevance for the management of firearms incidents.

Police Complaints Authority 23 Chapter Three: Family and key informant interviews

As part of the review, family members or their representatives were contacted for the 11 individuals who were killed as a result of the incidents reported in the study. The aim of these interviews was to gain an understanding of their experiences of both the police shooting and the subsequent investigation.

Three families agreed to be interviewed for the study and one other family member outlined his views in an e-mail to the review team. One further contact was obtained via the family’s legal representatives. Thus in six of eleven cases (54.5%), no information at all was forthcoming. This means that there is a problem with the representativeness of the views obtained and that we cannot conclude with any confidence that the issues summarised below adequately represent all of the families of those fatally shot by the police. Furthermore, it is not even possible to assume that, where communication with a family was achieved, the interviewee or correspondent can be regarded as the ‘spokesperson’ for the whole family.

A second source of information was obtained from a broader range of police groups and NGOs involved in family representation and campaigning for changes to the system. These included police organisations such as the Police Federation, ACPO, HMIC and the forces involved in the shootings. The views of relevant NGOs were also obtained as part of this ‘key informant’ phase of the study.

a. Informing the family: Several of the families interviewed expressed concern at the delay between the shooting and their being informed. This began with the notification of the shooting to the family and, in three of the incidents, all of which occurred in the street, with the identification of the body. In one case the family heard first through a friend, and in another the information originally provided by the police was inaccurate. In another case, the body had not been searched adequately and so the delay in identification of the body could have been avoided.

b. The provision of information:This reflected a more general concern, expressed by family members, about the paucity of information provided to families and, where information was provided, dissatisfaction with the delays in the police communicating information. One of the side effects of these perceived delays was that it reduced family members’ sense of involvement in the investigation.

c. Disclosure and information: This sense of dissatisfaction was exacerbated by police failure to act on families’ requests for particular pieces of information and that the information they were given was occasionally wrong. One family was inaccurately informed

24 Police Complaints Authority about how many shots were fired, while another shooting was known to the press before the family had been informed due to problems with identification of the body. Among the most unsatisfactory aspects of the police management of the shootings for several of the families contacted were that limited information had been provided, that what information they were given was often slow in arriving, and that these factors contributed to the sense of exclusion they experienced.

The NGO Inquest raised concerns about the information provided to families; specifically, that the SIO’s report should be disclosed before the inquest9.Families themselves were unsure what documents they had received and what others existed. In several instances the family did not feel that they knew what to expect from different bodies, or what they could reasonably request from the police about the investigation.

This was compounded by problems associated with the role of the FLO. One family felt that the FLO was not provided with sufficient information to be able to support them, another family was not offered this facility while a third was located too far away for it to be of much assistance. Indeed, the father of one of the shooting victims was not even informed by the FLO of the date and location of the inquest. The general perception was that the FLOs were as helpful as they could be but were not adequately equipped, and that they were too closely linked to the police investigation of the shooting. d. Impartiality of the process: While the Police Federation considered that anonymity should be afforded to all officers who have discharged a firearm, several families of those fatally shot by police felt that this was unacceptable and indicative of a double standard being applied. One family felt that this double standard was particularly striking around the issue of statement taking. While they felt that they were treated like ‘criminals’, there was considerable concern that, because of the nature of de-briefing, “the officers were given time to work out what was true and false and they got time to get their story straight”. The perceived ‘privilege’ afforded police officers led to concerns about the impartiality and fairness of the process. e. Legal Aid: This sense of imbalance also arose as a result of financial inequalities during the investigation and inquest process. One family received no financial assistance at all, another was not able to afford legal representation at the inquest, while the police interests were well represented. Several families felt that they were given no advice about the availability of legal aid and that the police forces were not supportive in informing them about the procedures and stages involved in such incidents. f. Police co-operation with investigations: A related issue which was raised was the practice of some police officers under investigation refusing to answer questions during interview, relying on a prepared statement and/or pocket book note. To some family members, this was compounded by the right during an inquest for a witness not to have to answer any question which could incriminate that person. This led families to believe that, even if the officers did not have anything to hide, they were not actively participating in a

9There remains a general rule against a right to disclosure of an Investigating Officer’s report on grounds of Public Interest Immunity (See Taylor v Anderton (Police Complaints Authority Intervening) [1995] All ER 420, CA).

Police Complaints Authority 25 search for the truth about the events that precipitated the fatality. In one case, this was compounded by the Coroner (at inquest) speaking to the officers but neither speaking to nor acknowledging (far less appearing to sympathise with) the family.

g. Crown Prosecution Service: Questions raised by family members over the impartiality of the criminal justice system were also extended to include the CPS. While the Police Federation felt that the CPS allowed the views of the families and campaign groups to influence cases against police officers, family members and NGOs believed that the lack of criminal charges against police officers demonstrated that the CPS was biased in the opposite direction. Further concerns were expressed about the unwillingness of the CPS to explain such decisions and others perceived the timing and method of communication used by CPS to be insensitive.

h. Role of the PCA: This provokes questions about the role of the PCA, with mixed views reported by the family members. In one incident for which there had been two supervising members from the PCA at different times, the family member interviewed felt that one PCA member had been very helpful but that his predecessor had been of little benefit to them. Several of the family members interviewed felt that the PCA should have played a more central role, as the body most family members would have trusted. While one family member felt that the PCA representative was ‘useless’, and while communication from the PCA was on occasion blunt in tone, it is evident that, in the minds of several family members, the PCA has a key role in managing the process and co-ordinating the flow of information to family members. Greater and more prolonged involvement from the PCA would have been welcomed by several interviewees.

i. SIO and investigating force selection: One of the key processes which caused concern to a number of the families was around the selection of investigators. There was concern expressed by several interviewees that the investigating force bordered the force in which the incident occurred, leading to fears that the senior police officers would know each other and that this would compromise their impartiality.

j. Discipline of police officers: Concerns about the neutrality of the investigation process were accentuated for one family by the perceived lack of disciplinary action taken against the officers involved in the shootings, and the lack of information about the disciplinary process given to families. This was an issue that caused distress to one family who wanted to know the nature of the allegations, attend the hearing and participate. The explanation given about discipline was inadequate, while the same family felt that they had been excluded from the misconduct process and that they were given little information about the hearing or its implications.

k. Resolution of incidents: Many of these concerns about the disciplining or prosecuting of officers arose because the families felt that the fatal shooting could have been averted. Among the issues that were considered unsatisfactory in this respect were: their own involvement in resolution, or rather the lack of this; the use of alternative ‘less lethal’

26 Police Complaints Authority options; the co-ordination of agencies to prevent the need for shooting; the rationale for the tactics selected; and issues of police training. There were also some ancillary issues that provoked anxieties among family members. One frequent perception was provided by the father of one of the shooting fatalities who argued that, “I do not feel particularly vengeful against the officer who pulled the trigger. Rather it is the system that permitted it that I would like to see changed”. • The involvement of carers: There was disquiet that the carers of people with severe mental illness, often family members, were not involved in attempts at incident resolution. It was felt that individual knowledge of the person, particularly when they were both highly stressed and vulnerable as a result of mental illness or substance use, may have enabled a successful de-escalation that was not possible when the police armed response escalated the risk. • Co-ordination of the police and other agencies: A similar concern was expressed about the adequacy of co-operation and co-ordination with health and social services during the incident, particularly for vulnerable individuals. While one parent was concerned about the lack of facilities in the area for alcoholics, and about the adequacy of the police response to intoxicated individuals, another father believed that “My son was executed, without any due process, for being drunk, for being a nuisance and for making threats he was quite incapable of carrying out”. The management of vulnerable populations was not perceived as being adequately handled by the police in several of the shootings included in the review. One of the families felt that the death should have been prevented as their son was “80% disabled with depression and anxiety” and had contacted the police only two weeks earlier about his possession of a pistol, rifle and a knife. • The use of alternative, ‘less lethal’ options: All of the families contacted were surprised that less lethal options could not have been used, whether this involved the use of police dogs, the use of negotiators or electric shocks, stun guns, or baton guns. Although many of the technological alternatives are not currently available to police officers in operational deployments, the family perception was that all other alternatives should have been explored to prevent the perception that the police used lethal force too early in the incident. One family member commented, “Even a dog is usually allowed to bite someone before it is put down”.10 • Early resolution: A related concern was that the length of time between the arrival of the armed officers at the scene and shots being fired was too little and that insufficient time was taken to carry out a risk assessment and to evaluate options before the lethal shot was fired. Although the officers involved may argue that the more time taken to resolve incidents, the greater the risk to officers, suspects and the general public, the families may fear that “What was once the last resort in a desperate situation, the calling in of armed officers, has now become almost the first choice course of action at the first sign of difficulty”.

10 This reveals a concern at the use of force by police pre-emptively. It also reveals a common misunderstanding of established law governing the use of force in self-defence or in the defence of others. This permits pre-emptive action in response to a threat so long as the action is proportionate to the perceived threat.

Police Complaints Authority 27 • Police training: Issues around firearms training were a major concern for the police staff associations and the families of people shot by the police. Their concerns included that not enough time was spent on training armed officers, while at least one family member felt that there was not enough time provided between the police officer completing their training and going out on the streets. • Resources for firearms work: The police representatives also expressed concern about the resourcing of firearms training and that there were not enough armed officers to respond to incidents. The associations were also concerned that there were not enough support services such as police dogs or negotiators to provide adequate alternatives to the use of lethal force. • Ancillary police issues: Confidence in the adequacy of the police response was further undermined in the minds of some family members by organisational or administrative failures that provoked concerns about general organisational competence. This included the concern that the police did not communicate internally and so had not picked up the warning signals about individuals or, where these had been identified, they had not been communicated to the armed officers attending incidents. Similarly, the discovery by one family that the officers had booked out the wrong guns for the operation and that the weapons were mixed up again after the operation, led them to perceive the police attitude as lackadaisical and indicative of a general lack of organisational competence. These issues provoked family concerns that the tragedies that occurred were, at least partly, the responsibility of a poorly managed and incompetent police response.

Whether factually accurate or not, this is the experience of those who agreed to participate in the review and their perception of the police actions and subsequent investigations. As a result of the low number of fatal police shootings in the review period, and the non- participation of so many families, generalisations based only on these comments should be treated with caution, although they have proved a valuable resource in framing and understanding the cases outlined in the chapters that follow.

28 Police Complaints Authority Chapter Four: Summaries of the cases included in the review

For each of the 24 cases included in the review, a brief and anonymised outline of the incident is presented in chronological order in this chapter. The aim of this section is to provide a brief factual outline of the incidents – for those incidents where the investigation is not yet completed, a much shorter summary is provided, largely based on what has been confirmed through ongoing investigative work.

Case A

Ethnicity: White British Date of shooting: 1998 Time: 04.17 Home Force: Investigating Force: Kent County Constabulary Type of incident: Pre-planned Outcome: Fatal shooting Number of shots fired: 1 Number of hits: 1 Weapon held by suspect: None Weapon type: Not applicable Criminal proceedings, if any, against police officer(s): One officer was tried for murder, alternatively manslaughter, and acquitted on the direction of the judge after the close of the prosecution case. Four officers (one constable, two inspectors and a ) were charged with misconduct in a public office. CPS discontinued proceedings against the constable before trial and offered no evidence against the other three at the start of their trial and they were acquitted. Inquest verdict: None to be held (due to criminal trial) Disciplinary action, if any: The was given advice by the Police Authority and the Deputy Chief Constable was suspended from duty pending disciplinary proceedings. He retired from the police service on medical grounds before the hearing was held. Three were given advice; two constables and one sergeant were admonished. The PCA recommended formal disciplinary charges against three officers, subsequently agreeing to withdraw the recommendation for one of the officers. A hearing has not yet been held. Was there a complaint?: Yes

Police Complaints Authority 29 A had been the subject of an investigation into the supply of drugs which had gone dormant and was believed to be an associate of a suspect being sought for a wounding. In seeking the individual believed to be responsible for the stabbing, the flat in which he lived was made the subject of an armed raid. A was in the flat asleep with his girlfriend.

This flat was in a small complex, the internal layout of which was unknown to the officers carrying out the raid. The officers detailed to A’s flat were positioned with another team allocated to the flat next door. They all entered by force through the door from the landing and found themselves in a small common entrance area. The door to the other flat could be seen and the team entered it by force. The door to A’s flat was not seen. Officers then discovered that it had been concealed by the open landing door and then gained entry by force.

The noise caused by police activity had woken the occupants of the flat and A had got out of bed to investigate the disturbance. The delay in police reaching the flat’s bedroom door, caused by their lack of knowledge of its internal layout, resulted in A having almost reached the bedroom door when armed police opened it and entered. The first officer to enter the room discharged a single shot to A’s chest resulting in a fatal injury, later claiming that he did so because he believed A was armed and he feared for his life. A was found to be naked and unarmed.

30 Police Complaints Authority Case B

Ethnicity: White British Date of shooting: 1998 Time: 20.19 Home Force: Bedfordshire Police Investigating Force: Type of incident: Spontaneous Outcome: Fatal Number of shots fired: 1 Number of hits: 1 Weapon held by suspect: Yes Weapon type: Non-firing imitation Colt 1911 self-loading pistol Criminal proceedings, if any, against police officer(s): None Inquest verdict: Lawful killing Disciplinary action, if any: None Was there a complaint?: No

B was known to have had a history of heavy drinking and there were reports from the probation service that B had been suffering from depression. On the day of the incident, B’s girlfriend arrived at his home and thought she saw someone breaking into the flat, so called the police. However, the apparent intruder was B who had left his keys in a public house and so was climbing in through the kitchen window as he had no other means of entry.

When the first police officers arrived at the scene they were threatened by B who pointed what appeared to be a handgun at them (it turned out to be a replica). At this point, they called for armed support and four firearms officers attended, deploying themselves around the parking area at the rear of the block of flats and at the front. It was not known by the officers that the individual in the house was B.

Although a negotiator could not be contacted, the police Silver Commander, a superintendent, did telephone the house occupant. B was not coherent during this conversation. While armed officers attempted to talk to B throughout the incident, it wasroughly one hour and forty minutes after armed officers arrived that the shot was discharged. At one point in this conversation B identified himself to the superintendent, thus establishing that he was the sole individual in the flat. However, B did not reply to subsequent questions and returned to the window of the house where he pointed his weapon at one of the armed officers. The officer felt that his life was threatened and discharged a single shot that hit B in the chest resulting in fatal injuries.

Police Complaints Authority 31 Case C

Ethnicity: White British Date of shooting: 1998 Time: 00.45 Home Force: MPS Investigating Force: MPS Type of incident: Spontaneous Outcome: Serious injury Number of shots fired: 1 Number of hits: 1 Weapon held by suspect: Yes Weapon type: Several knives Criminal proceedings, if any, against police officer(s): None Inquest verdict: Not applicable Disciplinary action, if any: None Was there a complaint?: No

C had a history of self-harm, including suicide attempts from drug overdose and stabbing himself. He also had a history of heavy drinking. On the day of the incident, C had been involved in a domestic incident with his wife, during which he threatened to kill her, ending with him on a common balcony, shut out of the house, banging at neighbours’ doors, one of whom called the police.

When the officers arrived, C had a knife with him inside the flat and threatened to kill the police officers. As further officers arrived with shields, there was a skirmish at the door, resulting in a pane of glass in the door being smashed, C attempting to stab an officer through the door, and C being sprayed with CS spray, which appeared to have no effect. As he retreated into the flat, C threw a knife at one of the officers causing a deep cut in his hand.

At the arrival of armed officers, C came down the stairs with a knife in each hand. As the officers backed off, C advanced to the communal area, still carrying a knife in each hand. When C lunged at one of the officers, a single shot was fired hitting C in the groin with the bullet exiting through his right buttock. After the shot, the officer kicked C in the body in an attempt to dislodge the knives. He was taken to hospital and subsequently recovered.

32 Police Complaints Authority Case D

Ethnicity: White British Date of shooting: 1998 Time: 02.17 Home Force: West Mercia Constabulary Investigating Force: West Mercia Constabulary Type of incident: Spontaneous Outcome: Serious injury Number of shots fired: 1 Number of hits: 1 Weapon held by suspect: Yes Type of weapon: Imitation 9mm Beretta handgun Criminal proceedings, if any, against police officer(s): None Inquest verdict: Not applicable Disciplinary action, if any: None Was there a complaint?: No

During the course of the evening of the incident, D had drunk part of a bottle of wine and a quarter bottle of whisky with his partner. As he left his partner’s house he had said “The easiest way for me to die is to get shot holding my replica gun”. He had apparently been depressed throughout the evening and had been drinking steadily. He was also a member of a local gun club.

The incident arose from a traffic collision that resulted in D pulling a gun on individuals involved in the incident. D was driving a friend’s car while drunk, having taken it without consent, and the weapon was an imitation handgun that he initially waved at officers without appearing to attempt to fire. He had gone to a farmhouse to telephone the police to inform them of the incident displaying a handgun to the occupants and reporting this to the police during the telephone call.

The police were then called and D was challenged, resulting in the deployment of the police dog, after around 15 minutes of unsuccessful negotiation. However, this was not successful as the dog stopped before it got to D, because it had been distracted by a noise. D aimed his imitation Beretta handgun at the dog-handler, at which point he was shot in the abdomen. He recovered from his injuries.

Police Complaints Authority 33 Case E

Ethnicity: Black British Date of shooting: 1998 Time: 10.15-10.30 Home Force: MPS Investigating Force: MPS Type of incident: Pre-planned Outcome: Minor injury Number of shots fired: 6 (but none at E who was hit by a ricochet) Number of hits: 1 (slivers from a bullet aimed at a dog) Weapon held by individual shot: None Weapon Type: Not applicable Criminal proceedings, if any, against police officer(s): None Inquest verdict: Not applicable Disciplinary action, if any: None Was there a complaint?: No

In the course of a murder investigation, believed to be drug-related, police officers went to the home of a man believed to have been involved in the murder. The aim was to arrest the individual and to secure evidence. The tactic selected was forced entry without prior warning. The officers knew that the house contained a Rottweiler dog, and the armed officers were instructed at the briefing to shoot the dog if it attacked. Eleven officers were sent to the house including eight firearms officers.

When they arrived at the scene, the officers entered the side of the house and the suspect failed to keep his dog under control. The dog bared its teeth and moved towards the officers, one of whom discharged five shots from his 9mm self-loading pistol. This slowed the dog before a second officer discharged a shotgun which knocked the dog over.

E was a visitor staying with the suspect at the time of the incident. As he went to observe the disturbance caused by the police operation, he felt a pain in his arm, looked down and saw blood. His wounds are described as superficial and he was not detained in hospital. The fragment of bullet which hit him came from a bullet that had hit the dog’s paw and rebounded upwards. E could not be located by the investigating team and no complaint has been made about the incident.

34 Police Complaints Authority Case F

Ethnicity: Black British Date of shooting: 1998 Time: 20.30 – 20.45 Home Force: MPS Investigating Force: MPS Type of incident: Spontaneous Outcome: Minor injury Number of shots fired: 3 (plus one car ramming) Number of hits: 1 Weapon held by suspect: Yes Weapon type: Sawn-off shotgun Criminal proceedings, if any, against police officer(s): None Inquest verdict: Not applicable Disciplinary action, if any: Not yet decided on matters subject to complaint Was there a complaint?: Yes, from the ex-partner of the individual shot

F had been the subject of complaints from a woman who was his ex-partner and mother of his child. Five days before the incident, the complainant reported to the police that F had threatened to shoot her. On the day of the incident, the officer called the complainant to ask her if there had been any more threats and to inform her that there were outstanding warrants against F. When F arrived at 20.30 to return her son, he accused her of calling the police. As unarmed officers approached F in his car, he produced a sawn-off shotgun that he pointed at the officers who took cover.

F then ordered the complainant and her son into his vehicle and drove off, followed by a number of marked police vehicles, with the officers also having called for armed assistance. When the armed vehicle took over as lead car in the ‘pursuit’, they witnessed F pointing his weapon at both officers and members of the public. When F stopped the vehicle and took aim at one of the officers in the ARV stopped directly across from him, an armed officer fired three rounds at F, one of which struck F on the hand, who then withdrew his gun and drove off.

Because F was again pointing his weapon at police vehicles and members of the public, one of the police vehicles rammed F’s vehicle. Subsequently, when F was forced into a petrol station forecourt, “armed officers carried out a controlled removal from the vehicle, firstly of [F] and secondly [the complainant]”. Both were subsequently handcuffed although the complainant was then identified as an innocent party and re-united with her son.

Police Complaints Authority 35 Case G

Ethnicity: White British Date of shooting: 1999 Time: 19.48 Home Force: Investigating Force: West Mercia Constabulary Incident type: Spontaneous Outcome: Minor injury Number of shots fired: 4 (2 shots fired by each of two officers) Number of hits: 2 Weapon held by suspect: Yes Weapon type: Imitation rifle Criminal proceedings, if any, against police officer(s): None Inquest verdict: Not applicable Disciplinary action, if any: Superintendent given advice on an ancillary matter (failure to complete the operations document) Was there a complaint?: No

Police were called to the area following an incident in which two young girls were threatened by a man with a gun. Although the police conducted a search, they were unable to locate the man. Three ARV’s attended the incident, manned by a total of six armed officers.

G was known to have a history of addiction problems, and was known to have suffered from mental illness, with both of these issues having been discussed during the briefing for the armed officers. He came from a broken family and had been in care at various points during his childhood. There was police intelligence five days before the incident indicating suicidal intent and two days before the shooting he was found in possession of a gun. His mental health problems were known to social and health services and to the probation service.

G himself had called the police providing the address he was at. A containment was placed on the premises and unsuccessful attempts made to negotiate with G. When he attempted to leave the premises he raised his rifle to threaten one of the officers who feared for his life. Two officers discharged their weapons each on two occasions, with two of the shots hitting G in the thigh and buttocks. The injuries sustained were not serious.

36 Police Complaints Authority Case H

Ethnicity: White British Date of shooting: 1999 Time: 03.30 Home Force: Devon and Cornwall Constabulary Investigating Force: Dorset Police Type of incident: Spontaneous Outcome: Fatal Number of shots fired: 2 Number of hits: 1 Weapon held by suspect: Yes Weapon type: Air rifle Criminal proceedings, if any, against police officer(s): None Inquest verdict: Lawful killing Disciplinary action, if any: None Was there a complaint?: No

H had joined the army in 1996 and served in Germany and before being discharged in 1997 for possession of an imitation firearm with intent to resist arrest. Following a night out with his girlfriend at a club, H returned home with her at about 01.00 hours and argued with her about a man she had been talking to. When she went to bed, he smashed glasses and discharged an air-rifle into photographs before leaving. At 02.27 the police received an anonymous call that a man was walking through the town centre with a gun. It transpired that this call was made by H himself. At around the same time, officers on patrol noticed H and approached him, resulting in H pointing his air weapon at the officers and telling them to back off. As the police backed off, H pointed his weapon at their car and chased them. The officers requested the assistance of an ARV.

A temporary Silver Commander was nominated, firearms authority granted and further officers called, including a dog handler, a negotiator and further ARV’s. At around 03.00 the armed officers arrived at the scene. At around 03.30, H was located and when armed officers arrived at the scene, he ran towards them with his rifle at his shoulder, aiming at them through the telescopic sights. Ignoring police challenges, he continued to advance closing the distance to 40 yards, before stopping and aiming at the officers. At this point, fearing for his life, one of the armed officers fired two shots – the first missing and the second striking H on the left shoulder and knocking him to the ground. The bullet disintegrated and caused severe haemorrhaging to internal organs and shock. He was taken to hospital but pronounced dead at 04.20. The 12 shot magazine of H’s rifle contained four pellets, creating the possibility that he may have discharged the weapon anumber of times in the earlier part of the incident.

Police Complaints Authority 37 Case J

Ethnicity: White British Date of shooting: 1999 Time: 15.53 Home Force: Surrey Police Investigating Force: Hampshire Constabulary Type of incident: Spontaneous Outcome: Fatal Number of shots fired: 1 Number of hits: 1 Weapon held by suspect: Yes Weapon type: Air weapon – Colt 1911 replica Criminal proceedings, if any, against police officer(s): None Inquest verdict: Lawful killing Disciplinary action, if any: Misconduct hearing for one Chief leading to a caution (for failure in the performance of duties). Advice was also given to one sergeant. Was there a complaint?: No

J had a history of mental illness, alcohol and drug abuse, having had a nervous breakdown when his marriage collapsed when he was 31. His wife reported that he was a long-term alcoholic, with a history of violence, an obsession with guns and problems with self-esteem. At times he had been prescribed Diazepam and anti-depressants, had attempted suicide and had been treated for alcohol problems. In March 1999, J threatened to shoot himself unless he was given Diazepam, but finally it was resolved when he admitted that he did not have a gun – he was subsequently admitted to hospital under s.136 Mental Health Act 1983. J had been drinking heavily in the week prior to his shooting and was worried about a court case. On the day before the shooting J had been drinking heavily in the company of his partner.

On the morning of the shooting, J sent his girlfriend to get ammunition for his air pistol, which she failed to do, so they returned home and drank a bottle of wine. During this time, he asked his girlfriend to shoot him, and pointed the gun at her causing her to flee from the house in panic to a neighbour’s house. At 14.15, this neighbour phoned 999 and told the operator that J had threatened his girlfriend and threatened to shoot himself, although she was by that time safely out of the house.

38 Police Complaints Authority Following a meeting with the Tactical Advisor, four armed officers in two ARV’s went to the scene along with a dog handler. During conversation between the officers and J, he is reported to have shouted “Oh fuck off, you just want to shoot me, go ahead and shoot me”, estimated at around 15.00. After problems locating a negotiator, officers at the scene informed J that the negotiator, who was not at the scene, would phone him, but J did not answer the telephone. After the armed officers called J to the window of the house, J raised his air pistol and aimed it at armed officers, one of whom fired a single shot knocking J over and fatally wounding him at 15.53 – almost exactly 90 minutes after the initial 999 call had been made. At the post mortem, the alcohol level identified in J’s blood was 350 micrograms per 100 ml – a state of gross drunkenness, and there was also evidence of Diazepam use. J’s weapon was discovered to be unloaded and, even if loaded, would have been of insufficient velocity to penetrate human skin.

Police Complaints Authority 39 Case K

Ethnicity: White British Date of shooting: 1999 Time: 09.18 Home Force: Devon and Cornwall Constabulary Investigating Force: Devon and Cornwall Constabulary Type of incident: Pre-planned Outcome: Serious injury, K was shot in the face but survived Number of shots fired: 2 Number of hits: 1 Weapon held by suspect: Yes Weapon type: Sawn-off shot-gun Criminal proceedings, if any, against police officer(s): None Inquest verdict: Not applicable Disciplinary action, if any: None Was there a complaint?: No

K was one of three men involved in an armed robbery of a jewellers’ shop. He is believed to have been part of a gang of eight that carried out robberies which involved entering jewellers wearing balaclavas and brandishing a sawn-off shot-gun. The police mounted a pre-planned operation. This operation involved two armed officers at each of two locations where the armed robbery was believed to be potentially occurring.

At 9.00 am the officers in the shop were informed that the three suspects were approaching the jewellers. K entered the shop and said “This is an armed robbery” at which point the officers emerged and pointed their weapons at him (both MP5 Carbine weapons) before K had pulled his shot-gun from his bag. However, K produced the shot-gun which he pointed at the officers, one of whom fired a first shot which he believed to have had no effect and so discharged a second shot which successfully incapacitated K.

In-store video evidence corroborated the officers’ account of the event. The first bullet missed, hitting a wall behind the suspect and the second struck K close to the eye and fragmented against his cheekbone. K’s weapon was not loaded although this would not have been known to the officers.

The SIO, drawn from Devon and Cornwall, concluded that there were no disciplinary issues. The operation was believed to have been planned as effectively as possible, a view supported by two sets of external experts.

40 Police Complaints Authority Case L

Ethnicity: White British Date of shooting: 1999 Time: 19.54 Home Force: MPS Investigating Force: Surrey Police Type of incident: Spontaneous Outcome: Fatal shooting Number of shots fired: 2 Number of hits: 2 Weapon held by suspect: None Criminal proceedings, if any, against police officer(s): None Inquest verdict: Open Disciplinary action, if any: Not yet decided Was there a complaint?: Yes

Police received a report from a member of the public that a man with a sawn-off shot-gun in a blue plastic bag had left licensed premises. Two armed officers in a vehicle were assigned to conduct a search for him. L was seen by them walking in a nearby street carrying something wrapped in a blue plastic bag. The police saw L walk around a corner and out of their view. They parked and left their vehicle.

When they reached the corner they saw L still walking away. Both officers challenged him from the rear. In evidence at the inquest into L’s death, both officers stated that he turned around to face them, raising what they believed was a sawn-off shot-gun, causing them to believe that one of them was about to be shot. This resulted in each of them firing a single shot from their handguns. One of these shots, to L’s head, caused immediate fatal injury.

It was then discovered that the article wrapped in a plastic bag was not a firearm at all but a wooden table leg. L had collected this from a relative who had been mending it. Scientific evidence cast doubt on the accuracy of the accounts given by the officers as to the position of the officer who fired the fatal shot and the position of L’s head when he was shot. However, the evidence of one independent witness supported the officers’ claim that L turned towards them and raised his arm. The inquest jury returned an open verdict, having been given a choice by the Coroner between lawful killing and an open verdict.

Police Complaints Authority 41 Case M

Ethnicity: Black British Date of shooting: 1999 Time: 10.37 Home Force: MPS Investigating Force: Thames Valley Police Type of incident: Pre-planned Outcome: Minor injury Number of shots fired: 1 Number of hits: 1 Weapon held by suspect: None Type of weapon: N/A Criminal proceedings, if any, against police officer(s): None Inquest verdict: Not applicable Disciplinary action, if any: None Was there a complaint?: Yes

Following an armed robbery members of the Flying Squad (SO5) mounted an operation close to a post office that involved both static and mobile surveillance. Two sets of armed officers were in vacant buildings and others in unmarked police cars. Intelligence had been received that M had access to a 9mm firearm and that he was addicted to cocaine.

Having spent the early morning watching a number of sub-post offices, the three individuals suspected of involvement in the earlier robbery were in the vicinity of the post office in a stolen Vauxhall Astra. As the security guard left the van to make a delivery of £15,000 cash to the post office, two of the suspects ran towards him, and M gestured as if he had a gun in his trouser pocket. The guard laid the security box on the ground where it was picked up by M who then ran towards the waiting car.

At this point, the officers intervened, challenging M who was shot in the hand by a single shot fired by one of the officers. The injury was not serious, although M alleged that the shot was fired immediately after the challenge, giving him no opportunity to respond.

42 Police Complaints Authority Case N

Ethnicity: White British Date of shooting: 1999 Time: 14.32 Home Force: MPS Investigating Force: Hertfordshire Constabulary Type of incident: Spontaneous Outcome: Serious injury Number of shots fired: 1 Number of hits: 1 Weapon held by suspect: Yes Weapon type: Imitation Beretta 9mm pistol Criminal proceedings, if any, against police officer(s): None Inquest Verdict: Not applicable Disciplinary action, if any: None Was there a complaint?: No

N had a five-year history of mental illness, including suicidal tendencies, although these were linked to his misuse of alcohol and crack cocaine. He was on bail for affray, offensive weapons, wounding and attempting to corrupt a police officer, and felt that he was being persecuted by the police. First arrested at 15, he had a lengthy criminal history, primarily for theft but including violent crimes. Two days before the shooting, N had been detained in hospital under s.136 Mental Health Act 1983, from which he absconded on the day of the shooting having been granted leave to go to the hospital shop and, at that time, he had threatened suicide. He repeated this threat when he telephoned his mother on the day of the shooting.

On the day of the shooting, N was granted an hour’s leave from a psychiatric hospital, from which he did not return, catching a bus into the town centre. Having collected what may have been the gun from a friend, he then spoke with another friend telling her that he could not go on, conducting this conversation while holding a bottle of vodka. Having threatened an acquaintance with his gun while walking along the road, N phoned 999 at 14.07 requesting SO19 and saying that he had had enough. He then entered his local public house and asked for a bottle of whisky, which he received. He then returned home before coming back to the public house and demanding a drink and threatening the bar-staff with his weapon.

Police Complaints Authority 43 At 14.17 two police vehicles arrived at the scene where N was talking with a friend. He immediately aimed the silver-coloured handgun at the unarmed officers in the cars, who reversed out of the street and requested urgent assistance. The unarmed officers then tried to clear the area while witnesses, who were known to N, tried to calm him down. As officers arrived, their positions meant that N was able to walk up to one (unoccupied) police vehicle at one point and strike the bonnet of another. However, two of the witnesses approached N during this ‘containment’, one of whom tried to get the gun from N and grappled with him for it, before N put the gun in his mouth (this happened eight minutes after the first police vehicles arrived).

As N walked past a police van and down past his local public house, he pointed the gun at a close friend who feared for his life. At 14.31 the ARV arrived, the officers armed themselves, took up a partly-protected position and issued a challenge to N. He ignored the warning and walked towards the armed officers. At 14.32, as he walked towards the armed officers challenging them, a single shot was fired by one of these officers, which hit N in the chest. The period between the arrival of the armed officers and the firing of the shot is timed as 32 seconds. Although the resulting injury was serious, N survived. The weapon held by N was a blank firing imitation pistol, although it did look like areal gun and is reported to have been fired by him.

44 Police Complaints Authority Case O

Ethnicity: Asian Date of shooting: 2000 Time: 02.35 Home Force: MPS Investigating Force: Type of incident: Spontaneous Outcome: Minor injury Number of shots fired: 1 Number of hits: 1 Weapon held by individual shot: None Criminal proceedings, if any, against police officer(s): None Inquest verdict: Not applicable Disciplinary action, if any: None Was there a complaint?: No

Following an alleged kidnapping and threats around the extortion of money, an individual approached the police saying that he had been kidnapped in connection with drug debts. The individual had cuts to his forehead believed to be the consequence of being struck with a black handgun, which had also been stuck down his throat. He had at one point been taken to a house and beaten up and, in a separate incident, had shots fired at him. An ARV was requested at 00.02 on the night of the incident.

The police then mounted an operation to observe the three individuals believed to be involved, whose car was seen outside the address given by the witness. The Tactical Advisor recommended a forced entry at the given address, but the Gold Commander wanted more information prior to authorising the operation.

The Tactical Advisor felt that this delay prevented the use of the optimal strategy for challenging the suspects at the address. At 02.34 unarmed officers observed the target vehicle moving off from the address, and the Silver Commander instructed that an ‘armed stop’ be carried out. The decision to carry out a ‘non-compliant stop’ involved the illumination of blue lights and pulling in front of the vehicle, forcing it to stop, with other ARV’s to the side and the back of the target vehicle.

The armed police officers ran to the target car shouting “armed police, get out of the car”. One officer stated that he ran so fast at the car that, in his attempt to stop himself, he smashed one of the windows of the car. Another of the officers, in challenging O, discharged his weapon, hitting O in the arm. The officer stated that his pistol had become entangled in something, while holding a ‘life hammer’ in his other hand and, as he was taking hold of the suspect by the right shoulder, he became aware that a shot had been fired. He claimed that he then became dizzy and felt detached from what was going on around him, and that at no point had he deliberately discharged his gun. O had no criminal history. No evidence was offered against O and he was found not guilty of all offences. No weapon was found in the car.

Police Complaints Authority 45 Case P

Ethnicity: White British Date of shooting: 2000 Time: 22.00 Home Force: Investigating Force: West Midlands Police Type of incident: Spontaneous Outcome: Minor injury Number of shots fired: 7 Number of hits: 2 Weapon held by suspect: Yes Weapon type: Imitation 8mm pistol loaded with CS cartridges Criminal proceedings, if any, against police officer(s): None Inquest verdict: Not applicable Disciplinary action, if any: None Was there a complaint?: No

During the christening of his child, P had been drinking excessively and an argument took place between him and his girlfriend. During the argument, he produced an 8mm handgun which he used to hit his girlfriend and with which he threatened to kill her.

A number of officers arrived at the scene following calls from the public concerning a man in the street with a gun including one ARV with two occupants. The ARV officers encountered and challenged P, who ignored the challenge and pointed his handgun at the officer, reportedly saying “You’re having it”. One of the officers drew a Beretta Centurion Pistol and discharged seven shots, two of which hit P with a further two shots entering his clothing without causing injury. He was hit in the abdomen and the leg.

The weapon carried by P was an imitation pistol although it was capable of firing and contained CS irritant cartridges, albeit none were actually fired. P subsequently wrote a letter of apology to the officer involved, although at the time he had threatened to make a complaint.

46 Police Complaints Authority Case Q

Ethnicity: White European Date of shooting: 2000 Time: Approximately 20.00 Home Force: MPS Investigating Force: MPS Type of incident: Spontaneous Outcome: Serious injury Number of shots fired: 2 Number of hits: 2 Weapon held by suspect: Yes Weapon type: Axe Criminal proceedings, if any, against police officer(s): None Inquest verdict: Not applicable Disciplinary action, if any: None Was there a complaint?: No

Q, a Spanish national, had been resident in the UK for five years at the time of this incident. Little is known about his life here; he apparently had few friends or acquaintances and his family had had no contact with him since his departure from Spain in 1995. His mother is known to have had a history of mental health problems and this may have had a detrimental effect on the mental health of her son. He had reportedly been unwell for some time before his move to , although there is no record of him having received formal psychiatric treatment in the UK.

On 24 August 2000, Q was ejected from a supermarket following an assault on a security guard. Five days later he returned, to be met by the same security guard. When challenged, he showed the guard a hand axe attached to his belt and walked into the store, which appears to have been relatively busy with shoppers at the time. The guard’s manager phoned the police and followed Q around the store.

An ARV containing three SO19 officers arrived in response to the call and entered the store following a briefing by the security guard. They split up, with two officers drawing their extendable batons and taking up position in one aisle, and the third drawing his Glock pistol and standing in the next aisle. Q was challenged, at which point he turned to face the officers with the batons and took the axe from his belt, raising it to his shoulder and advancing towards them, smiling. He was ordered to stop and drop his weapon but did not do so. The third officer then shot him, although this apparently had no effect other than to concentrate Q’s attention on this officer instead. He turned towards him, still smiling and holding the axe at shoulder-height. He was ordered again to drop his weapon by the armed officer, to no avail, and was shot a second time, which caused him to fall to the ground. The axe was kicked away and emergency first aid was commenced. Q was subsequently taken to hospital and successfully treated for his wounds. An analysis of his pre-transfusion blood was negative for alcohol and drugs.

Police Complaints Authority 47 Case R

Ethnicity: White British Date of shooting: 2000 Time: 23.36 Home Force: Investigating Force: Greater Manchester Police Type of incident: Spontaneous Outcome: Fatal Number of shots fired: 3 Number of hits: 2 Weapon held by suspect: Yes Weapon type: Air rifle Criminal proceedings, if any, against police officer(s): None Inquest verdict: Lawful killing Disciplinary action, if any: Advice to two officers on ancillary matters Was there a complaint?: No

R is described as being obsessed with military matters, having a long criminal history and an army career punctuated by disciplinary problems and a spell working as a mercenary in Croatia. He had a long-standing although irregular history of contact with psychiatric services, including treatment for both depression and PTSD. On 8 June 1999, he was assessed as suffering from personality disorder relating to both PTSD and alcohol abuse.

On the day of the shooting, R argued with both his father and his partner and spent much of the afternoon in a public house. He then walked into a North Yorkshire and, following a conversation with the desk officer, put a gun on the counter which he then pointed at the officer, who dived out of sight. R then left the police station taking the rifle and was not traced until reports were received of an incident in a West Yorkshire psychiatric hospital two and a half hours later.

At the hospital, R pointed his weapon at reception staff ordering them to put down the telephones they were using to contact the police. While there, R at various points said that he wanted to be admitted, that he was expecting armed police to arrive and that he would shoot the first person through the door. Initially two unarmed officers were sent to the hospital followed, eight minutes later, by the dog handler and, 15 minutes later, by the ARV. The two officers in the ARV attempted a ‘mobile containment’ of R who was adjacent to the hospital building, before engaging in a conversation with R who at times asked the officers to shoot him. In total four firearms officers were in due course present at the scene.

R moved towards the car park ignoring the police challenges. He crossed a road into a wooded area where police attempted to ‘run over’ R with an ARV but only struck him a ‘glancing blow’. R then aimed his rifle at a police officer. One officer discharged three shots when he believed that he was going to be shot. Two shots hit R and the third hit the telescopic sight of his weapon. He died shortly afterwards from the injuries sustained.

48 Police Complaints Authority Case S

Ethnicity: White British Date of shooting: 2000 Time: 10.10 Home Force: Gwent Police Investigating Force: South Wales Police Type of incident: Spontaneous Outcome: Minor injury Number of shots fired: 3 Number of hits: 1 Weapon held by suspect: Yes Weapon type: Imitation Magnum 38 Criminal proceedings, if any, against police officer(s): None Inquest verdict: Not applicable Disciplinary action, if any: None Was there a complaint?: No

Having read that Gwent was the least policed area in the UK, S bought a replica pistol and made his way by train to Gwent where he identified a suitable bank. Pulling a balaclava over his face, he entered the bank and produced the gun. Although a member of the bank staff activated the alarm, S managed to get away with £9,000. A bystander phoned the police as S left the bank, and, when the officers arrived, an officer challenged him so he ran away, dropping his holdall as he did so. However, as the officer was gaining on him, he pulled his gun and aimed it at the officer telling him to back off.

As other police officers arrived, they instructed S to put the gun down and tried to clear the main street (he was openly walking around with his gun). One of the officers used CS spray on S when the gun was pointed at an officer. With the first level of containment established, three firearms officers arrived. As S aimed at one of the firearms officers, the officer, having made the challenge, discharged his weapon three times, hitting S on the right shoulder. Although S was able to run away, pointing his weapon at officers as he did so, he was later contained in a garden where he gave up and was arrested.

Police Complaints Authority 49 Case T

Ethnicity: White Irish Date of shooting: 2000 Time: 18.08 Home Force: MPS Investigating Force: West Mercia Constabulary Type of incident: Spontaneous Outcome: Fatal shooting Number of shots fired: 1 Number of hits: 1 Weapon held by suspect: Yes Weapon type: Knife, corkscrew Criminal proceedings, if any, against police officer(s): None Inquest verdict: Lawful killing Disciplinary action, if any: None Was there a complaint?: No

T had a disturbed education, involving an expulsion from school for fighting, and a long history of contact with psychiatric services. In March 1999, he was detained under the Mental Health Act, and was engaged with psychiatric services regularly from this point until May 2000, generally as an in-patient. He also had a history of drug-taking and claimed to be using crack cocaine in the period before his death. Up to the date of his death, Tappeared to have been taking his medication and appeared mentally stable at interview 10 days before the shooting. However, his mother reported that his mental state had deteriorated significantly in the three days immediately before his death.

The incident occurred following a siege at the home of T who had barricaded himself into his house. His mother telephoned the police at 8.16 am to say that her son was holding her (his mother) and his girlfriend as hostages. His girlfriend was tied up and was being dragged around the flat whenever T moved around. He also threatened her with a knife on a number of occasions.

At 5.22 pm, T allowed his mother to leave the flat unharmed. At 6.08 pm, a decision was made to enter the premises by force as T appeared to be becoming more agitated and aggressive and, as soon as T heard the officers enter the premises, he started to attack his girlfriend with a metal corkscrew. A police marksman, situated in an adjacent flat, shot T through the window of the house, hitting him in the chest causing fatal injury.

50 Police Complaints Authority Case U

Ethnicity: White British Date of shooting: 2000 Time: Approx 15.45 Home Force: Merseyside Police Investigating Force: West Midlands Police Type of incident: Spontaneous Outcome: Minor injury Number of shots fired: 2 Number of hits: 1 Weapon held by suspect: Yes Weapon type: Imitation shot-gun (two pieces of piping attached together) Criminal proceedings, if any, against police officer(s): None Inquest verdict: Not applicable Disciplinary action, if any: None Was there a complaint?: No

U is believed to have been responsible for a series of armed robberies in Merseyside in October and November 2000, carried out using what appeared to be a double- barrelled shot-gun.

Shortly before the incident, two robberies took place, after which witnesses were able to give police the registration number of the car used in the second one. The car was spotted by a senior detective who followed the vehicle only to have what appeared to be a shot-gun pointed at him by the occupant, who subsequently left the vehicle and walked away at 3.35 pm. At 3.41 pm an ARV response was authorised by the Force Incident Manager, with two two-man crewed ARVs responding.

One of the armed officers reported that on arrival at the scene he was immediately confronted by U with the shot-gun, who then ran away. In spite of shouting “armed police, stand still” on three occasions, these instructions were ignored by U, who began to “swing the shot-gun backwards and upwards towards him”. This led the officer to fear for his life, so he fired his weapon twice. After the second shot U fell to the ground, having been shot in the right thigh – the entry wound is described as to the rear of the right thigh. The weapon carried by U was in fact two lengths of tubular metal fastened together and held in a plastic bag.

Police Complaints Authority 51 Case V

Ethnicity: White British Date of shooting: 2001 Time: 22.08 Home Force: Merseyside Police Investigating Force: Greater Manchester Police Type of incident: Spontaneous Outcome: Fatal No of shots fired: 2 Number of hits: 1 Weapon held by suspect: Yes Weapon type: Samurai sword Criminal proceedings, if any, against police officer(s): Not yet decided Inquest verdict: Not held yet Disciplinary action, if any: Not yet decided Was there a complaint?: No

Police officers were called to V’s home where he was experiencing a period of mental illness. He left the house brandishing a samurai sword at the officers who backed off as he ignored their instructions to drop his weapon. As he approached a local public house, one armed officer feared that he may be a significant danger to members of the public and so shot him as he advanced. He died from the resulting injury. At the time of writing, the file is with the CPS and no inquest has been held.

52 Police Complaints Authority Case W

Ethnicity: Black British Date of shooting: 2001 Time: 15.22 Home Force: MPS Investigating Force: Type of incident: Spontaneous Outcome: Fatal No of shots fired: 6 Number of hits: 4 Weapon held by suspect: Yes Weapon type: Imitation handgun Criminal charges, if any, against officers: Not yet decided Inquest verdict: Not yet decided Disciplinary action, if any: Not yet decided Was there a complaint?: No

The police were called when W brandished an object which was believed to be a gun, and two ARV’s were despatched to the scene. When W was located, he was challenged by two armed officers, one of whom discharged his weapon six times hitting W with four of these shots. The item carried by W turned out to be a gun-shaped cigarette lighter. The investigation is complete but no decision on prosecution has been taken. As a result, there has been no inquest or trial to date.

Police Complaints Authority 53 Case X

Ethnicity: White British Date of shooting: 2001 Time: 01.45 Home Force: Derbyshire Constabulary Investigating Force: West Midlands Police Type of incident: Spontaneous Outcome: Fatal No of shots fired: 1 Number of hits: 1 Weapon held by suspect: Yes Weapon type: Shot-gun Criminal charges, if any, against officers: None Inquest verdict: Lawful killing Disciplinary action, if any: None Was there a complaint?: No

X had been drinking wine throughout the afternoon and evening on the day of the incident. Following his girlfriend’s arrival at his home, a heated argument occurred resulting in his girlfriend calling the police. When the officers arrived, they asked X to leave, a request with which he complied. However, as the officers subsequently left, they saw him back at his girlfriend’s front door. As they approached him, he produced a sawn-off shot-gun which he pointed at the officers, telling them to get back in their car which they did.

From the car, they called the control room operator who requested ARV and police dog attendance. Four armed officers attended along with three dog handlers. Two armed police approached the front of the house where they saw X. He ignored their instruction to lay down his weapon and aimed his weapon at one of the officers who responded by firing a single shot from his Steyr carbine. The shot hit X in the left side of his torso, causing him to fall to the ground. In spite of the officers’ first aid endeavours and resuscitation attempts in the hospital, he died as a result of his injuries. The unloaded shot-gun carried by X would have been capable of firing a live round with only minor adjustment.

54 Police Complaints Authority Case Y

Ethnicity: White British Date of shooting: 2001 Home Force: MPS Investigating Force: MPS Type of incident: Spontaneous Outcome: Fatal No of shots fired: 1 Number of hits: 1 Weapon held by suspect: Yes Weapon type: .22 Criminal proceedings, if any, against police officer(s): Not yet decided Inquest verdict: Not yet held Disciplinary action, if any: Not yet decided Was there a complaint?: No

Although the incident arose from a domestic dispute, there is no evidence that Y had a history of drug or alcohol problems, or was suffering from mental illness at the time of the shooting. The police were called to a domestic incident which developed into a siege with armed officers in attendance. Attempts at negotiation, although prolonged, were not successful.

Y emerged from his bedroom indicating his desire that the police shoot him. At the time he was holding a small .22 revolver that had been fired into the door shortly before. As he emerged through the door he raised the firearm and was fatally shot. His death was the result of a single gunshot wound to his upper body. This appears to be the only incident in the review (out of 24) where not only was the weapon involved real, but it was actually discharged during the incident. The investigation has not yet been completed.

Police Complaints Authority 55 Chapter Five: Quantitative analysis of the 24 cases included in the review

The individual cases were analysed as a group to assess common patterns in terms of the characteristics of the individuals shot, the circumstances of the shooting and the post- incident management of the incidents. The method employed below is based on the use of a standardised pro forma developed through initial piloting with two cases and subject to subsequent discussion (included as Appendix 2). The forms were completed on the basis of information in the PCA case files and the completed forms were entered on the statistical package SPSS. This chapter provides a summary of the descriptive results.

It is important to note that there are a number of limitations to the data presented. The first limitation is a result of using a standard form that may simplify what are complex and unique incidents. The second limitation is database-related and partly results from the attempt to ensure that the report is up-to-date. Four investigations had not been completed by the time of writing and so the material available is only partial in these cases. This limitation is compounded by inconsistencies in the amount of information available from completed files.

The majority of the data presented below is ‘factual’ and merely attempts to record aspects of the incidents that are reported in the PCA files. However, where the report comments on the adequacy or effectiveness of aspects of incident management, this will be made explicit, and is based on the views of the firearms expert.

Descriptive data from the incidents The data presented below cover 24 shooting incidents in which the police have shot members of the general public between January 1998 and November 2001, resulting in 11 fatalities. The forces involved in the cases were: • MPS (11 cases); • Merseyside (3 cases); • Devon and Cornwall (2 cases); and • West Yorkshire, Bedfordshire, Surrey, Gwent, West Midlands, West Mercia, Derbyshire, Sussex (1 case each).

56 Police Complaints Authority Six of the incidents occurred in 1998, seven in 1999, seven in 2000 and four in 2001. In all 24 incidents only one individual was shot, although six of the 24 incidents involved more than one suspect – two incidents involved two suspects, three involved three suspects and one involved four suspects.

Using the classification employed in the Burrows Report, four of the incidents were ‘robberies’, 10 were ‘domestic incidents’ and 10 would be classed as ‘other’ incidents. This is further indication of how varied are the events included in the review. A second level of classification is that four of the 24 were defined as ‘pre-planned’ police operations while the remaining 20 were ‘spontaneous’ incidents.

In terms of the conditions at the time of the incident, 16 occurred outdoors, six inside buildings and two in vehicles; eight occurred in natural light, 12 in artificial light, one in darkness, two in torchlight and for one this information was not available. In none of the incidents were there reports of adverse weather conditions that may have affected the outcome, and where lighting conditions changed over the course of the event, this tended to result from the onset of dusk and the use of police lighting equipment in contained situations. However, in none of the 24 incidents is there any clear indication that climatic conditions had an impact on the incident.

In total, there were 55 shots fired in the 24 incidents (an average of 2.3 per incident), of which 32 hit individuals (or 58.2%) – although six of the shots (all in the one incident) were aimed at, and hit a dog, with a ricochet striking one of the individuals. If this incident is excluded, the hit rate is 63.3% (31 hits from 49 shots fired) see case E in Table 3 overleaf. It is worth noting that in the 11 fatal shootings, a lower average number of shots were fired (1.9) but with a higher hit rate (76.1%) – in six of 11 a single shot was fired. It is important to note that, in considering the restraint shown by armed officers, each of their weapons would have contained between 15 and 30 bullets, suggesting that, even when armed officers do make the rare decision to fire, they do so in a controlled manner consistent with the ACPO Firearms Manual.

Police Complaints Authority 57 The main classifications of each of the incidents is provided in Tables 3 and 4 below:

Table 3: Summary of the cases involved in the review

Case Location Pre-planned/ spontaneous Outcomes Shots fired/hits A Sussex Pre-planned Fatal 1/1 B Bedford Spontaneous Fatal 1/1 C MPS Spontaneous Serious injury 1/1 DW Mercia Spontaneous Serious injury 1/1 E MPS Pre-planned Minor injury 6/1 F MPS Spontaneous Minor injury 3/1 G Merseyside Spontaneous Minor injury 4/2 H D&C* Spontaneous Fatal 2/1 J Surrey Spontaneous Fatal 1/1 K D&C Pre-planned Serious injury 2/1 L MPS Spontaneous Fatal 2/2 M MPS Pre-planned Minor injury 1/1 N MPS Spontaneous Serious injury 1/1 O MPS Spontaneous Minor injury 1/1 PW Mids Spontaneous Minor injury 7/2 Q MPS Spontaneous Serious injury 2/2 RW Yorkshire Spontaneous Fatal 3/2 SGwent Spontaneous Minor injury 3/1 T MPS Spontaneous Fatal 1/1 U Merseyside Spontaneous Minor injury 2/1 V Merseyside Spontaneous Fatal 2/1 W MPS Spontaneous Fatal 6/4 X Derbyshire Spontaneous Fatal 1/1 Y MPS Spontaneous Fatal 1/1

As can be seen from the above table, there is no clear relationship between the type of incident and the likely outcome. What is evident, however, is that the more recent shootings have been associated with more serious outcomes, with five of the last six shootings resulting in fatalities. It is also worth noting that only three forces have had more than one shooting in this period, so for lessons to be learned for the majority of forces, co-operation and communication between forces is required.

*D&C, Devon and Cornwall Constabulary

58 Police Complaints Authority Characteristics of the individuals shot All of the individuals shot were male, with a mean age of 33.8 years (range = 18 – 62 years). Information on ethnicity was available for all 24 of those shot, of whom 17 were described as white British, two as ‘white other’, four as Afro-Caribbean, and one as Asian. For 23 incidents, the person shot spoke English. Further characteristics of the incidents are provided in Table 4 below which, on the basis of the IOs’ reports, lists some of the possible factors that may have been significant determinants of the police discharges.

Table 4: Possible explanatory factors in each of the 20 cases for which reports were available

Case Robbery Domestic Mental Intoxicated History of Weapon Was Health at time of substance type firearm incident problems real? A- ----None - B- -XXXPistol Imitation C- XXXXKnife - D- -XX-Pistol Imitation E- -X-XNone - F- X---Shotgun Yes G- -XXXRifle Imitation H- XXX-Air-rifle Yes J- XXXXAir-pistol Yes KX ---XShotgun Yes L- --X-None - MX ---XNone - N- -XXXPistol Imitation O Kidnap - - - - None - P- X-X-Pistol Imitation Q- - X - - Axe - R- XXXXAir-rifle Yes SX ---XPistol Imitation T- XX-XCorkscrew/Knife - UX ----Shotgun Imitation

From the table it can be seen that four of the shootings resulted from attempted robberies (and another from a reported earlier kidnapping related to drug use), that seven of the incidents involved domestic disputes (while another possibly did) and that 12 contained elements that may imply that they were ‘provoked shootings’. It is important to note that five of the individuals shot were not in possession of a weapon (real or imitation) at the time of the shooting, and that only one of the individuals involved discharged their weapon when police officers were present, though not aiming at or hitting officers or members of the public. Furthermore, the distinction between real and imitation is more complicated than it first appears. While all but one of the imitations were manufactured to look like the genuine weapon (and so indistinguishable visually), even two of those without a weapon – one of those shot made the shape of a gun in his pocket, while another had an object wrapped in a bag – appeared, to the officers, to be in possession of a weapon. Similarly, at least one of the imitations would have been capable of firing with only a very minor adjustment.

Police Complaints Authority 59 Intoxication, addiction and mental health factors Eleven of the 24 individuals for whom information was available were described as intoxicated at the time of the incident – 10 with alcohol and one with a combination of alcohol and illicit drugs, while 10 were known to have a history of addiction problems, although this generally only became known to the police officers present during or after the incident. Eleven of the individuals were described as having mental health problems, although this is likely to be an under-estimate, as such a classification generally required contact with treatment services. The range of mental health problems included a history of self-harm, depression, anger management problems and psychosis. In only five of the 24 cases in the review is there no indication of either mental health or substance misuse problems.

Criminal histories of the 24 individuals shot Furthermore, 15 of the 24 individuals involved were known to have criminal histories, with previous convictions including arson, possession of weapons, armed robbery, and assault, although these histories would not necessarily have been known to the officers at the time of the incidents nor are they necessarily relevant to the shooting incidents themselves.

Categorising the shootings included in the review Although there are a number of common characteristics that link the shooting incidents included, there are difficulties in developing a taxonomy of incidents based either on the characteristics of the individuals shot or the nature of the incident itself. The system used by Burrows involved three categories – robbery (n=7), domestic (n=9) and ‘other’ (n=7). However, there are two problems with this system. First, it permits a ‘catchall’ group almost as large as the other groups and, second, it does not permit a classification by two of the main factors identified by both Burrows and the current review, namely mental health and substance misuse.

For this reason, the classification system developed for the current review is based on a two-tier categorisation. At the first level, each incident is classed according to the “rationality” of the actions of the person shot. This person can be broadly classed, at the time of the shooting, as behaving in either a rational manner, or behaving in an irrational manner (as a consequence of mental health problems and/or the short or long term effects of illicit substance use). The period during which this judgement is made is on behaviour over the entire incident that resulted in the shooting. According to this classification, nine of the 24 individuals (37.5%) shot could be said to have behaved in a rational manner in the period immediately preceding the shooting, with the remaining 15 (62.5%), engaged in irrational behaviours prior to the shooting.

The second level classifies behaviour within this initial distinction. For the nine “rational” cases, the reasons for their engagement with armed police related to their involvement in armed robbery (n=4), other criminal behaviour (in one case avoiding arrest) and four cases in which there are concerns that the shooting involved either accident or human error (which does not imply necessarily that an error was made by the firing officer). These cases are listed in table 5 below:

60 Police Complaints Authority Table 5: Analysis of shootings within the review classified as ‘rational’

Case Rational or Classification Description irrational ARational Accident or Armed police officer mistakenly believed that human error A was holding a gun ERational Accident or E hit accidentally by splinters from a bullet human error ricocheting from a dog (the intended target) FRational Other crime F was shot while evading arrest KRational Armed robbery K was shot in the process of robbing a jewellers’ shop LRational Accident or Armed police officers mistakenly believed human error that L was holding a gun MRational Armed robbery M was shot while attempting to carry out an armed robbery of a post office ORational Accident or O was shot by an accidental discharge during human error an armed operation relating to a kidnapping SRational Armed robbery S was shot by an armed officer while escaping following an armed robbery URational Armed robbery U was shot while attempting to evade arrest following a series of armed robberies

For the remaining 15 incidents, that have been classed as ‘irrational’, a further breakdown of the sources of the irrational behaviour is shown in Table 6 below, based on domestic incidents, substance intoxication or mental health issues (including suicidal ideas). It should be noted that all of the incidents in this group were spontaneous incidents.

Police Complaints Authority 61 Table 6: Analysis of shootings within the review classified as ‘irrational’

Case Rational or Classification Description irrational BIrrational Intoxication B was incoherent during communication with officers as a result of heavy drinking and was shot in his own home CIrrational Domestic/ Following an argument with his wife, C Provoked shooting (who also had a history of substance problems and suicide attempts), was shot after threatening armed officers DIrrational Intoxication/ D reported to his partner his desire to be Domestic/Provoked shot, had also been drinking heavily and shooting phoned the police himself GIrrational Mental health/ G phoned the police himself to tell them his Provoked shooting address and had a history of addiction and mental health problems HIrrational Domestic/ H, who had been drinking and had argued Intoxication/ with his partner, phoned the police himself to Provoked shooting tell them he was armed JIrrational Domestic/ Having asked his partner to shoot him and Intoxication/ threatened to shoot her, J was drunk when Provoked shooting challenged by police NIrrational Intoxication/ With a history of mental health problems, Provoked shooting/ N walked through a town centre with a gun in Mental health one hand, and alcohol in the other, challenging police officers PIrrational Intoxication/ Following a domestic dispute at a christening Domestic at which he had been drinking heavily, P threatened guests with a gun QIrrational Mental health Q had a known history of mental health problems, and had phoned the police several times in a paranoid state RIrrational Mental health/ R had a long history of mental health Intoxication/ problems, had argued with both father and Provoked shooting/ partner on the day of the shooting and had Domestic been drinking heavily TIrrational Mental health T had a history of addiction and mental health problems, but significantly deteriorated in mental well-being in the days before the shooting

62 Police Complaints Authority In each of the four cases for which the investigation has not been completed at the time of writing, there are clear indications of suicidal intention in one, of the combination of intoxication and domestic dispute in a second; and mental health problems in the third. The behavioural and psychological characteristics of the final case have not yet been clearly established.

This categorisation scheme provides a framework for classifying the 24 incidents in the current review using a two-tier method in which the basic distinction is the perceived rationality of the behaviour of the individual shot in the period prior to the shooting. The second level of analysis is a less exclusive system for identifying risk factors that appear to have been instrumental in shaping the behaviour of the individual during the firearms incident.

Weapons carried by the victims of police shootings Offering a taxonomy of weapon types for the victim is considerably more difficult than categorising the guns used by the police in these incidents. The first problem relates to the cases in which the weapon the police perceived the individual to be carrying was not what was identified afterwards. The second difficulty is that ‘imitation’ or ‘replica’ weapons are not readily identified as such, and, furthermore, many are capable of modification so that they can be discharged in some way. Nonetheless, it was possible to classify the weapons possessed by the individuals shot into the following five broad categories:

1. Edged weapons (n=4): Two of those shot were in possession of knives, one was armed with an axe and the fourth with a sword. 2. Firearms capable of discharge (n=7): Seven individuals had , air weapons or rifles that were capable of being discharged at the time of the incident. However, four of these seven weapons were not loaded at the time of the incident. 3. Replica or imitation firearms (n=7): Seven individuals had imitation weapons, although one of these contained and was capable of firing CS incapacitant canisters. 4. Other objects (n=2): One individual had a bag wrapped around a table leg and the second two lengths of metal tube attached in a plastic bag. 5. No object (n=4): Four individuals had no object in their possession at the time of the shooting.

However, even in the ‘no object’ category, two individuals were believed by officers to be carrying weapons – one of whom was making the shape of a gun in his pocket in the course of a robbery and the other was not carrying any objects but was believed to have been doing so by the firing officer.

Police Complaints Authority 63 Use of weapons by the individuals shot In only one instance, where a police officer was stabbed in the hand by a knife that was thrown from inside a house, did the use of the weapon by the suspect result in injury to an officer. This occurred before the firearms team arrived and, in only one of the incidents, was a member of the public injured after the arrival of firearms officers. One officer received a superficial leg wound in the course of one of the incidents as a result of over-penetration of a bullet fired from a police gun. Three members of the public (two of whom were partners of the individuals shot) had been assaulted in the period immediately prior to the arrival at the scene of the firearms officers.

However, in 14 of the 20 incidents in which the investigation had been completed, the ‘weapon’ (defined as the object or action perceived as a threat by the firearms officers involved) was pointed at someone before the firearms officers arrived, and this also happened in 17 of these 20 incidents after the arrival of the firearms officer. This would indicate that the arrival of the firearms officers was not clearly linked to an escalation in the aggressive responses of the individuals subsequently shot.

In terms of the accuracy of the police response, 11 of the incidents involved a single shot which hit the intended target, and in two further incidents two shots were fired both of which hit their intended targets (see Table 3). However, the definition of ‘hit’ used in the study includes all shots that contact with the body, whether it was the intended body part or not. Many of the shots failed to hit the central body area that armed officers are trained to aim at, with a number of shots hitting the arms, the legs or the head. In all of the remaining 11 incidents at least one shot missed its target, with one incident involving two hits from seven shots and another involving one hit (on the hand) from three shots (this was especially dangerous as the shots were at an individual in a car also occupied by two involuntary passengers).

Characteristics of the officers involved Information was less consistently available on the characteristics of the police officers who were involved in the shootings, although this is, in part, due to the fact that a number of the investigations had not been completed at the time of writing. In three of the incidents, more than one officer fired their guns and in the remaining cases for which information is provided (n=21), only one officer was involved.

The data are available on 25 police officers involved in these incidents – 22 constables, two sergeants and one inspector. Twenty-two of these 25 officers were from ARV teams, while seven were members of specialist firearms units. All 24 officers for whom gender was given were male and all 22 for whom the information was provided were of white British ethnic origin. The officers’ ages were only provided for eight officers with a mean of 36.0 years and length of time in the police force for only 10 officers (mean = 14.7 years). All 24 officers for whom the information was provided were firearms authorised. There was marked variation in length of time as firearms trained (between 3 and 17 years), with the average length of time as a firearms trained officer being around six years. All twelve

64 Police Complaints Authority officers for whom the information was available had fired three classification shoots in the previous year, although the most recent type of training varied quite markedly. For the six officers on whom this was provided the mean length of time since the last course was 3.7 months, with the most recent course being either a practice shoot, a reclassification or a shooting test. However, the poor level of recording of recency or type of training makes drawing inferences in this area problematic. Clear and consistent guidelines for IOs on the inclusion and reporting in final reports of training and refresher training (as provided in Appendix 2) is strongly recommended. For only two of the officers is there a report of drug or alcohol testing and in both cases this is reported to have been negative.

Briefing and de-briefing of officers With regard to briefing and de-briefing of officers, there is again limited information to report. For 16 of the 18 officers for whom information was available, a briefing took place and is reported (this includes all four of the pre-planned operations). The picture is far less clear for the spontaneous incidents, with the most common form of briefing occurring via the radio (n=6), but for several of the incidents, the main form of briefing seems to have taken place on arrival on the scene.

A similar picture emerges for de-briefing, with information provided on de-briefing in only 11 incidents. Four of the officers were involved in immediate group debriefs, one was provided later by the Silver Commander, one involved the officers’ solicitors and one took place three weeks after the incident. The lack of adequate information on this issue, combined with variations in the nature of the de-briefs that are reported on, renders comparison unreliable. The purpose of the debriefs ranged from those relating to the collection of evidence for the investigation, to those concerned with the welfare of officers and the provision of legal advice to officers involved in incidents.

Eleven of the 14 officers, on whom data are available, were temporarily suspended from operational duty but in only one case was an officer suspended from the police force, and in this case six officers were suspended. At the time of the incident, the officers had been on duty for a mean of 5.4 hours – although it is worth commenting that one of the officers had been on duty for 10 hours and another for just under 12 hours. None of the officers involved reported any previous involvement in police shootings. Information on what the officers had been wearing at the time of the incident is available for 20 of the officers – the majority of whom were in uniform with body armour (n=16), although three were in police uniform with no armour and one was in plain clothes.

Police Complaints Authority 65 Weapons used and reasons given With regard to the weapons available to the officers involved in the incident, the most commonly used weapons were the MP5 (on nine occasions) and the Glock Pistol (also on nine occasions). Other weapons used included a Ruger Rifle, a Steyr Carbine, a shotgun and a Beretta Centurion pistol. In 16 cases, there are reports of what other weapons were available to the officers – in one case there were no other weapons, in six cases the MP5 and in nine cases the Glock 17 Pistol. For 13 of the incidents, reasons were available for the choice of weapon with the most common being the distance that the suspect was from the officer (on seven occasions), with one officer citing the location as the reason for the choice of weapon. The other reasons given were far more practical; in one because it was the only weapon available, one because of the immediate nature of the threat and one because of the nature of the incident. In one of the incidents, the officer used a handgun because he was not able to get the gun box open and the final case involved the use of a handgun because it was an immediate source of personal protection.

In the 18 incidents for which the information is available, the mean number of rounds fired by the first officer is 2.3 (range = 1-7). When there was a second officer involved who also fired (three cases of this are reported), two of these officers fired once and one fired twice. No officer fired more than one weapon in the course of an incident.

The mean number of ‘hits’ recorded for the incidents (excluding case E) is 1.35 (range = 1-4), a total of 31 hits from a total of 49 weapon discharges (63.3% of all shots fired hit their intended target).

Criminal and disciplinary outcomes Table 7 presents the criminal cases against the officers involved in each of the shootings, the inquest verdicts (for the fatal cases in which inquests have been held) and the disciplinary charges faced by police officers.

66 Police Complaints Authority Table 7: Summary of the criminal and disciplinary proceedings and inquest verdicts from each of the review cases

Name Criminal Coroner’s Disciplinary proceedings proceedings inquest AFive officers were NA Chief Constable received advice; Deputy charged, four were Chief Constable retired on medical grounds, tried, none were before disciplinary hearing. Three officers convicted. admonished and three received advice. PCA recommended formal charges for three officers. Charges against one officer withdrawn. A hearing has not yet been held. B None Lawful killing None verdict – 27.11.98 C None NA None D None NA None E None NA None F None NA Not yet decided on matters subject to complaint G None NA Superintendent given advice on ancillary matter (completion of documentation) H None Lawful killing None verdict – 9.8.2000 J None Lawful killing Misconduct hearing resulted in caution for verdict – 4.5.2000 for failure in performance of duties. Advice for sergeant K None NA None L None Open verdict Not yet decided – 21.7.2002 M None NA None N None NA None O None NA None P None NA None Q None NA None R None Lawful killing Advice to two officers on ancillary matters verdict – 2.5.2002 S None NA None T None Lawful killing None verdict – 18.4.2002 U None NA None V Not yet decided Not yet held Not yet decided W Not yet decided Not yet held Not yet decided X None Lawful killing None verdict – 8.11.02 Y None Not yet held Not yet decided

Police Complaints Authority 67 In only one case did the investigation lead to criminal proceedings. In this case, the principal officer stood trial for murder, alternatively manslaughter, and was acquitted on the direction of the trial judge at the conclusion of the prosecution case after a submission of no case to answer. Four other officers, including a superintendent, acting chief inspector and inspector responsible for planning and initiating the operation, were charged with misconduct in a public office. Proceedings were discontinued against a constable before the trial commenced. At the start of the trial of the remaining three, the prosecution, having reviewed the position, offered no evidence and they were acquitted.

Although none of the officers in the cases reviewed have been convicted at criminal court, there has been formal disciplinary action taken in two of the 19 cases that had completed the disciplinary investigation by the time of writing. In one case, one officer received a caution after an allegation of failure in performance of duties was found proved against him. In case A, two officers have disciplinary proceedings outstanding against them at the time of writing. In four cases, informal disciplinary action, such as advice, was given.

With regard to criminal charges brought against the individuals who were shot but survived (of whom there were 13), nine individuals were charged with criminal offences. Two others were detained in psychiatric hospitals under the Mental Health Act as they were not fit to stand trial. Both of the others were shot in error. One was hit by a ricochet from an over- penetrating bullet and the other was hit by an accidental discharge by the officer.

Formal complaints have been made and investigated following four of the 24 incidents reviewed. Two have been from family members of fatal shooting victims (A and L); one was from the individual shot in a non-fatal case (M), and one was from a person taken hostage by her ex partner in one of the incidents (F). Conclusions have been reached on two complaints investigations (A and M) and in one case (L) allegations about post incident issues, not related to the use of firearms, have been finalised, leaving other allegations concerning the shooting to be determined. In cases A and L, complaints have been upheld in part. In M, allegations were not substantiated.

68 Police Complaints Authority Chapter Six: Learning the lessons

The following section outlines the lessons to be learned from the incidents reviewed. These comments and recommendations outline what can be learned concerning the planning, control and conduct of operations. The aim is: to provide a critical analysis of the 24 incidents included in the review; to address the issues raised by the families of some of the victims; and to provide an outline of where changes may be made and steps taken to reduce the likelihood of errors occurring in the future and to minimise the chances of the police having no alternative but to use lethal force.

At the outset, however, it must be stated that the review has also established a disturbing lack of high quality evidence on which to base policy and practice decisions. Many of the inferences in the current review have had to be based on a small number of cases with very limited supporting information from existing research. The development of ‘good practice’ is predicated upon the collection and utilisation of a satisfactory information base. However, at present, there is inadequate and insufficient evaluation, review and research being undertaken by the police service or the Home Office in the area of police use of firearms. That the current review has had to rely on an eight-year-old ACPO review of 23 cases and overseas research as the evidence base is not satisfactory nor is this omission adequately addressed by the current review. There is a clear need for further research into the following areas:

1. The characteristics of those shot by the police and the main variables that increase the likelihood of being shot (which would include comparison with successfully resolved firearms incidents involving ‘matched’ suspects). 2. A research programme assessing the increased risks for vulnerable populations and examining the police responses to what are perceived to be ‘victim-precipitated’ police shootings. In addition to mental health and addiction issues, this programme should also examine other demographic risk factors such as the ethnicity, age and economic and social status of the victims. 3. An analysis of the characteristics of the officers involved in shootings – this would include an assessment of the decision-making features involved in the individual incidents as well as an assessment of their background characteristics, attitudes to police use of firearms and experience. It may also be useful to assess empirically the psychological and physical consequences of shootings on principal officers. This has obvious welfare implications as well as being relevant to the management of firearms units.

Police Complaints Authority 69 4. An assessment of the experiences of the non-fatal victims of police shootings. From those who are shot it may be important to record their perceptions of the event and their recollection of what led them to engage in behaviours that made officers fear for their lives or those of members of the public. 5. Systematic research assessment of the management of firearms incidents, including evidence on the use of police dogs, the consequences of rapid or protracted attempts at resolution and the use of different negotiation and challenge methods.

For each of these areas of investigation, a combination of comparative research, documentary-based and interview methods can be employed.

Recommendation 1: The Home Office should commission and fund a programme of research into police shootings and their circumstances with the research programme decided jointly by ACPO, the police staff associations, PCA, the Home Office and PSDB.

The overall rate of police discharge of weapons In the absence of more detailed information that is available across all forces, the authors have attempted to contextualise the incidents where shots were fired by using data from HMIC on the number of operations within each force. The table below is based on returns made by each force to HMIC on an annual basis.

In the period of the review (1998-2001), there were 24 occasions when individuals were shot by police officers from a total of 44,871 occasions on which police officers were issued with firearms (including ARV operations) throughout England and Wales. In other words, an individual was shot by the police once in every 1,870 firearms ‘operations’ (defined as firearms issues including ARV operations). Alternatively, the 11 fatal shootings means that in only one of every 4,079 firearms operations, is a fatal shot discharged (see Table 8 below). One possible interpretation of this finding is that we have no grounds for concern and that an average of less than three fatal police shootings per year, or one from every 4,000 firearms incidents should be a cause for recognising police professionalism and restraint, rather than provoking an investigation into what has gone wrong.

70 Police Complaints Authority Table 8: Number of incidents and number of authorised firearms officers in England and Wales and in the MPS, 1997-2001 (Source – HMIC)

Operations where ARV operations Officers authorities firearms issued issued England and Wales (including MPS) 1997-98 11,842 7,510 6,585 1998-99 11,005 7,906 6,411 1999-00 10,915 8,276 6,262 2000-01 11,109 8,179 6,064 MPS 1997-98 2,578 954 1,971 1998-99 2,742 1,573 1,951 1999-00 2,862 1,812 1,977 2000-01 1,862 1,380 1,940

For the MPS alone, which is the force with the greatest incidence of shootings in the review, there were 10,044 incidents where firearms were issued including 5,719 ARV operations in the period of the review. In the same period, the MPS was involved in 11 police shootings of which four were fatal. Thus, for all of England and Wales apart from the Metropolitan Police, there was a rate of one shooting for every 2,679 firearms operations and one fatal shooting for every 4,975 firearms operations. For the MPS, the rates are one shooting every 913 operations and one fatal shooting for every 2,511 operations.

This occurs against a context of a total of 1,707 shots fired in criminal incidents in the financial year 2000/2001 (Criminal Statistics, England and Wales, 2000–2001). This constitutes a rise of 21% on the previous year (n=1,413) and 64% on two years earlier (1998/1999). However, this increase is not reflected in the level of police shootings, which has remained relatively constant over the period of the review.

These data do demonstrate that, in the vast majority of firearms incidents, resolution is achieved without the need for weapon discharge, which reflects positively on the majority of firearms officers involved, their managers and trainers. However, as far as is known, none of the individuals shot by the police had injured others using firearms, and it is certainly the case that none of them did so in the course of the incidents included in the review. That is not to say, however, that they would not have done so – although only three were in possession of loaded firearms capable of harmful discharge at the time of the incident.

Police Complaints Authority 71 Furthermore, the finding that none of those shot in completed cases had fired intentionally at the police differentiates the current study cohort from that investigated in the Burrows Report. In a number of the incidents included in the Burrows review, the police were fired on by suspects, which did not happen in any of the cases in the current review where the investigation had been completed by the time of writing. In Case Y, a shot was fired by Y with the bullet striking a door, and officers had been behind that door earlier in the incident. However, the investigation has not yet been concluded, and so it is not possible to be definitive about this issue.

Understanding the context of police use of firearms Each day, the police deal with numerous calls which are perceived as life-threatening incidents but have either been over-stated or are successfully resolved with the officers involved often displaying considerable bravery in addressing and responding to what they believe to be a life-threatening incident. While the 24 cases in the review constitutes a small sample on which to base any generalisations, these cases open organisational practices and policies to a form of external scrutiny that has indicated the existence of individual and system errors that need to be addressed.

Some of the recurring themes identified across cases and over time may indicate omissions or limitations in policy or practice that only such an overview, distanced from the inidividual concerns and emotions of specific cases, has identified.

The majority of the discussion below will focus on potential areas of improvement for firearms teams and police managers, with only infrequent comment about the activities of other officers or emergency services and infrequent comments on the many armed and unarmed successes that do not result in the need to use police weapons. However, many of the problems identified here are to do with systems that involve, but may go beyond, the police to include NHS mental health, addiction treatment and social services. They are affected by broader social policy and public attitudes around the management of vulnerable populations and the role of the police reconciling individual needs with issues of public safety.

72 Police Complaints Authority The sections below will provide an outline of the main areas where issues have been identified which can be grouped into three broad categories:

A Management of the incident, which focuses on command structure and its impact on incident management, the availability and use of ‘less lethal options’ and issues around containment and the speed of the incident resolution; B Characteristics of those shot, which looks at vulnerable populations in terms of mental health issues, substance use, suicidal intentions and the resulting nedd for multi-disciplinary interventions; and C Post-incident issues, which examines the concerns of the family and the disclosure of information, the role of the investigator and the impact of each of the participating bodies in generation delays.

A. MANAGEMENT OF THE INCIDENT While there are a number of individual errors that have been identified by the SIO, many of these are accentuated by and embedded within organizational factors that indicate areas for improvement and clarification. Indeed, many of the concerns about firearms incident management and policy may have only become apparent as a result of individual error. A suitably self-critical and reflective police approach would work from the premise that the adverse incidents reviewed offer the perfect opportunity for the examination of possible organizational and structural weaknesses that are made manifest by the incidents which have resulted in police shootings.

1. Command structure and management of incidents In considering the adequacy of management, the key policy base is the ACPO firearms manual which outlines recommendations on key areas of firearms policy, although its use by individual forces is at the discretion of the Chief Officer. With regard to the ACPO manual, key issues that will be considered are the consistency of its adoption and utilisation, and reasons for local variation, its comprehensiveness and its relevance. The second document that will be relevant throughout this section is the report produced for ACPO in consultation with the PCA by Burrows that reviewed the incidents between 1991 and 1993. This provides a marker for both the consistency of incident profile and management over time and as a yardstick of whether key issues identified by Burrows have been addressed adequately in the intervening period.

1.1 Recording force decisions to diverge from national guidelines The complexity of tactical decisions has been acknowledged by the ACPO committee on the police use of firearms who meet to consider new tactics and advise on their appropriate use. In the only case where this issue arose, there is no evidence that such validation had been sought for what appeared to be the maverick use in that force of an entry technique,

Police Complaints Authority 73 referred to as the “Bermuda” tactic. This tactic, which may have contributed to the adverse outcome, involved the rapid entry to premises without maximising the intelligence gained about the location, and was regarded only as a tactic of last resort by many forces. Chief Officers should ensure that any new tactics or adaptations benefit from the advice of ACPO.

Recommendation 2: It is recommended that Chief Officers ensure that unique, local tactics devised in their force should be referred to ACPO, with HMIC advised accordingly.

1.2 Status of guidance on the police use of firearms The review noted that there were considerable differences in the way in which Chief Officers adopted the ACPO Manual of Guidance on Police Use of Firearms. Some adopted the Manual of Guidance in writing, while others referred to it within their own force policy document. However some of the operational practices of the force did not comply with the Manual in the cases examined, yet reference is not made to the intention not to comply at the time of adoption and many of the IOs attempted to use the Manual as the standard by which to judge the actions of officers, causing some confusion. Where the Manual vindicated their actions, some of the officers quoted the relevant section, but where actions challenged were not in the Manual they stated that it was only guidance. This confusing status is not satisfactory. It was also difficult to identify the link between Chief Officer’s policy decisions and the actions of officers around the adoption of the Manual. The link between the policy decision and operational behaviour appears broken.

Recommendation 3: It is recommended that the Chief Officers should adopt the ACPO Manual of Guidance, noting any areas of intended non-compliance, and that the consistency of Chief Officer’s policy and the operational actions of the force based on the use of the Manual are reviewed. Chief Officers should advise their police authority of any departures from the Manual and the reasons for each.

1.3 Accountability Firearms policy implementation should be included in the job description of one of the ACPO team who should be held responsible for compliance by the force, to strengthen the link between operational behaviour and policy decisions, with failure to do so a neglect of duty. This person should have ultimate accountability for the compliance of firearms operations with that policy. While ultimate accountability lies with the Chief Constable, the day-to-day responsibility should lie with the nominated firearms Chief Officer.

Recommendation 4: It is recommended that firearms policy is included in the job description of a Chief Officer who should be held responsible for compliance by the force, and this should be subjected to scrutiny by the relevant police authority and HMIC.

74 Police Complaints Authority 1.4 Planning The quality of planning in the spontaneous incidents in the review was primarily dependent on the duration of the incident, with greater time available leading to more thorough operation planning and implementation. However, this was not a universal rule – in one case, the armed officers had 12 minutes before arriving at the scene yet made no plans. In contrast, in another incident lasting just five minutes officers were able to deploy a less lethal option (a police dog) under the protection of a conventional firearm. In the opinion of the PCA firearms advisor, there were several instances of flaws in the planning of operations.

Case study one: Flawed planning – entry to building

When it is decided in a pre-planned operation that it is necessary for armed officers to enter a building, the Manual of Guidance recommends that detailed knowledge about the location and layout of the inside of the premises is obtained. As entry to buildings, particularly at speed, is a high-risk activity, it is logical to reduce that risk by providing information about the building. One force appeared to be utilising a specialised tactic as a general purpose entry technique, which in the target case was carried out without information about the layout of the building, partly as a result of time constraints placed on the operation.

Reliance on this tactic to overcome lack of knowledge of the layout of the building contributed to a delay in armed officers reaching one of the bedrooms. The result was that both the occupants were awake and one was just inside the door when armed police opened it. One fatal shot was discharged. In the opinion of the PCA advisor it is illogical and reckless to conduct a planned armed entry into premises without detailed knowledge of the layout of the interior. Only an immediate threat to life would justify such a deployment. There was no time constraint that made such action necessary before detailed intelligence on the internal layout could have been obtained.

The main concern in the above case and the one below is that the pragmatic tactics used resulted in an increased level of risk to the suspect, the officers and members of the general public. While it is acknowledged that there are practical, managerial concerns around incident volume and the need to reconcile achieving a timely conclusion with maximising safety, the methods used in both (which would be described as ‘proactive’ in each case), may have contributed to the adverse outcome and may have led to increased public risk.

Police Complaints Authority 75 Case study two: Flawed tactics – non-compliant vehicle stop

In one spontaneous incident the tactics to arrest suspects in a vehicle were decided by a constable who then asked other constables whether they agreed to a non-compliant stop and, when they did so, this became the tactic. If other tactical options were considered, they are not specified in the statements made by any of the principal officers. The problem is not that a constable proposed the tactic but that there was no intelligence that these particular suspects would be unlikely to comply with a standard stop. This was a tactical decision that should have been taken by the Silver Commander advised by the Tactical Advisor. The supervisor with responsibility to act as the Firearms Bronze Commander was not part of these discussions because he was also the Tactical Advisor and was with the Silver Commander at another location. This case identifies flaws with both the management of the response and the selection of tactical options, the combination of which may have contributed to the unsatisfactory outcome, which in this case was an accidental shooting.

1.5 The early resolution of incidents This issue has raised concerns about the general philosophy of early resolution. Most incidents were resolved quickly once contact was made with suspects by specialist firearms officers. This operational experience resulted in ARV crews being trained and authorised to make contact by challenging suspects quickly after their arrival at the scene thus giving potential for a prompt resolution of incidents.

Many incidents are quickly established not to be life-threatening and so are rapidly resolved with the minimum community disruption and restricted use of a scarce and expensive police resource. However this tactic provoked anxieties among families interviewed that unnecessary confrontations may be caused by an escalation of risk provoked by the immediate challenge of suspects. Although the officer’s actions at the moment of confrontation did not result in criticism from investigators nor were criminal or discipline offences revealed, this strategy may increase the likelihood of adverse outcomes in certain categories of case, particularly those involving vulnerable populations (see section 5 of this chapter). In one case, the IO recommended that “ARV training is reviewed to ensure that it creates the correct mind set in armed officers ensuring they do not consider early resolution as the only option.” In several cases, tactic selection led to the use of the most proactive tactics in the first instance, sometimes with little evidence to support claims that it was safer for the public, police and suspect. While the extent of vulnerability of the suspect may not be immediately apparent to the firearms officers, delaying actions will increase the time available to obtain such information and utilise it in developing suitable tactics.

76 Police Complaints Authority In two of the three fatal cases involving individuals shot when alone in their own homes, there was close containment and early and repeated challenges of the suspect. In each of these cases, the individual was extremely alcohol intoxicated at the time of the shooting and each had prolonged histories of depression (one had previously attempted suicide). In one of these cases, the repeated challenges eventually brought the suspect to the window, where he confronted and challenged police to shoot him. When he produced the gun they did so, fatally wounding him. In five other cases, the use of an immediate challenge by firearms officers on their arrival at the scene may well have escalated the incident and played a contributory role in the shooting. The rationale for early resolution is further challenged by the US finding that police use of deadly force is more likely when encounters are ambiguous or are characterised by an element of surprise (Fridell and Binder, 1988).

In another case, involving an initial contact with unarmed police officers, a negotiator was not used as the unarmed officers provided close containment and negotiation at the suspect’s front door. However, when an armed officer announced himself on arrival, there was a response that prompted the shooting. The request that the suspect put down his weapons provoked a reply of “I need them to kill you” and appears to have contributed to the escalation in activity in this incident. This resulted in one officer being hit with a knife thrown by the suspect and the suspect being shot. The key conclusion is that, particularly for vulnerable populations, the attempt at proactive resolution may increase the likelihood of the officers having no choice but to shoot the suspect.

Recommendation 5: The principle of using proactive resolution methods with individuals who are suspected, on the basis of intelligence or immediate evidence, to be mentally ill or under the influence of psychoactive substances requires urgent review and systematic monitoring and evaluation. Further, at the level of policy not incident, it is recommended that the selection of tactics should be reviewed by the Chief Officer responsible for firearms within each force to establish the justification required for the most proactive tactics to be selected as first choice.

1.6 Challenges by armed officers The issue of speed of resolution is also complicated by the strategy used by armed officers for challenging the suspect, in terms of the location of the officers in relation to the suspect. If a suspect does not respond to a challenge from armed officers but does not pose an immediate threat, then there is insufficient guidance for officers on alternative strategy or tactics. Suspects who are drunk, drugged or mentally ill, may fail to understand what is required of them, which has resulted in weapons being discharged in a number of cases. In such cases, and possibly in all cases, the officers should not position themselves in exposed positions, which will lead them to fear for their lives if the suspect comes into view with their weapon or what is assumed to be a weapon raised.

Recommendation 6: It is recommended that advice is obtained by ACPO from addiction and mental health professionals and from those with negotiating expertise on methods of approach and challenge, particularly in cases where the suspect is believed to be vulnerable, prior to the formulation or amendment of firearms policy.

Police Complaints Authority 77 A similar problem may arise when suspects are challenged from behind, which occurred in four of the cases in the review. In two of these cases the individual appeared to be turning round to aim a weapon at the officers while running away and in the other two they appeared to be turning towards the officers to confront them. It may be a normal reaction to turn towards the source of a challenge and, if this is likely to lead officers to fear for their lives and so discharge their weapons, then the process which can lead to this must be reviewed.

Insufficient attention appears to be given to the nature of the challenge (when it occurs, the distance between the officer and the suspect, the tone of voice or volume used), yet these factors may be significant in shaping the likelihood of compliance. It is reasonable to infer that cross-cultural concerns may impact on the likelihood of compliance, while the mental state of the suspect is also likely to be an important mediating variable.

Recommendation 7: ACPO must review the current practice of challenges including their rationale and consider alternative methods, styles and locations of challenging that may reduce the likelihood of weapon discharges, based on research commissioned by the Home Office.

1.7 Tactical advisors The Firearms Tactical Advisor provides advice to the commander of an incident on the deployment of armed police – the ACPO Manual of Guidance states that “they do not make any decisions or take independent action”. However, in five of the 24 incidents the officer who had the role of Tactical Advisor also had a supervisory responsibility for armed officers. As the Tactical Advisor was often some distance from the scene, it was not possible for one officer to fulfil both of these roles, as each role required them to be in a different location.

In addition there were two incidents where the Tactical Advisor who was also the supervisor decided to attend in neither of these roles but as an armed officer because they were nearest. However, this prevented the officer from fulfilling either the role of Tactical Advisor or supervisor. Where a Tactical Advisor attends an incident as an armed officer, another appropriately qualified officer should be dispatched to take over either the armed officer or Tactical Advisor role.

Recommendation 8: It is recommended that Chief Officers should ensure that Tactical Advisors do not have other roles that would conflict with this crucial tactical role during the course of firearms incidents. Where the incident necessitates that the Tactical Advisor takes on another role, they must be replaced as Tactical Advisor as quickly as possible.

78 Police Complaints Authority 1.8 Negotiators Although many firearms incidents are resolved successfully by the interpersonal skills displayed by armed and unarmed officers, the specialist skills of negotiators are required in certain kinds of incidents. Policy in relation to calling out negotiators to spontaneous incidents varied considerably between forces, with some forces having a policy where negotiators are immediately requested for firearms operations while in others they are used far more restrictively. While there may be reasons for such variation, it is more concerning that, in several cases, individuals with another specific role acted as negotiators, either because a negotiator had not arrived or as a result of the failure to call out a qualified negotiator.

This may indicate the need for the development of an intermediate level of training in negotiation to permit a greater number of firearms officers trained in this area for either immediate response or where fully qualified negotiators are not available.

Recommendation 9: It is recommended that ACPO review policy and procedures for the deployment of negotiators, and that officers should neither abandon their own role as firearms officers nor take over this specialist function without suitable training and instruction.

1.9 Command structure for firearms incidents Most incidents where a command structure was set up used the three-tier system of Strategic, Tactical and Operational identified by the colours Gold, Silver and Bronze respectively, so that command was based on role rather than rank. However, what should be a simple common system has become complex and difficult to understand, and may be inappropriate for most spontaneous incidents of brief duration examined in the review. In the spontaneous incidents, there are few examples where all three roles were both assigned and adequately fulfilled and the gaps arising in the management structure can generally be linked to weaknesses in the conduct of the operation. Although it is desirable where possible to attempt to set up this structure, its unwieldiness may suggest that a more timely and straight-forward method of determining strategy and management is required.

This conclusion was supported by the SIO in a number of incidents – one pointed to a “confusion of role between …. Gold and Silver which led to a delay in getting the appropriate authority”. Similarly, a second investigator commenting on a case within the same force recommended that “the importance of quickly establishing an effective chain of command needs to be fully understood and implemented”. He went on to argue that “there needs to be more clarity as to where the Tactical Advisor fits into the [name of force] chain of command”.

Police Complaints Authority 79 Command confidence appeared as important as command ability in ensuring successful outcome as it empowered senior officers to exercise the appropriate control over the progress of the incident. The combination of training and experience is the key to providing competent commanders and the review identified areas that would benefit from further consideration.

1.9(i) The role of Gold Commander The benefits of an experienced Gold Commander were demonstrated in a number of incidents. However, there were examples where Gold Commanders were not notified that a spontaneous incident was occurring until after the shots had been fired, while in one case a strategy was not set by Gold because he requested additional information, which had not been received by the time the incident had played out and a police shooting had occurred. In a further incident that occurred during the night, the Gold Commander was woken up at home as the incident was occurring, but he was unable to provide appropriate strategy because he was not sufficiently alert.

Recommendation 10: It is essential that Gold Commanders should be informed as soon as possible that a firearms incident is taking place and that Gold Commanders set an initial strategy even if they require additional information to finalise this strategy.

Recommendation 11: It is imperative that the Chief Officer ensures that each nominated Gold Commander receives appropriate training and that they can demonstrate that they have had sufficient training to fulfil this strategic role.

1.9(ii) The role of Silver Commander The review revealed that there were three main groups who performed the role of Silver Commanders:

Control Room Inspectors Geographic Uniform Inspectors Cadre of selected and trained Chief Inspectors and Superintendents

The rank of the Silver Commander in the majority of incidents was Inspector, as a result of the short incident durations. The difficulties associated with this ad hoc adoption of the Silver role was also identified in the Burrows Report.

The speed at which the structure for incident management was set up varied between incidents, resulting in some spontaneous incidents having little or no formal control, while the quality of the Silver Command was not acceptable in others, often as a result of a lack of training for Silver Commanders of Inspector rank. This problem was compounded by officers acting up who had not received the training for the substantive rank, a situation that occurred in six of the shootings (25%) included in the review. There were also incidents where the initial officers fulfilling command roles were left in post even though it was recognised that the incident was complex and their training and experience was minimal.

80 Police Complaints Authority Recommendation 12: It is recommended that Firearms Silver Commanders be selected, trained and assessed against core competencies. They should also re-qualify against these criteria at appropriate intervals to be agreed by ACPO.

Case study three: The role of Firearms Silver Commander

This issue arose during the inquest following a fatal police shooting as the trained Superintendent on call for firearms incidents in the area had a 100-mile journey to reach the scene. At the inquest, the duty ACC reported that “(the) Superintendent did not have command, and never did have command. The command would be invested in (the local) Inspector”. However, the duty Inspector reported that he was never the Firearms Silver Commander, so there was never a Firearms Silver Commander in charge of an incident that resulted in a fatal police shooting. This breakdown in the command structure for armed operations is unsatisfactory if it means that some incidents may then lack tactical command. In this case, there was a duty officer who exercised control over everything except the armed officers who then had to decide on their own actions without adequate tactical advice. This may place the armed officers and members of the public at unnecessary risk and requires that the command roles (particularly for the firearms officers) be clarified.

In some instances, the Silver Commander appeared to lack command confidence in dealing with the incident. This resulted in a de facto delegation of responsibility to firearm unit supervisors leading to difficulties in distinguishing decisions taken by the Silver Commander, as opposed to actions decided by the armed officers involved in the incident who made spontaneous decisions unrelated to strategy or tactics as events unfolded. The significance of this is that where proactive options are appropriate and decisions are required quickly, inexperienced Silver Commanders may not have the confidence to make those choices, yet remained in that role even after more experienced colleagues became available. The most effective command was apparent in incidents where the Silver Commander was drawn from a cadre of selected officers who were both well trained and experienced.

Recommendation 13: It is recommended that those who are expected to command a firearms incident have received appropriate training. They should be notified immediately an incident occurs. Where practical, it is recommended that a cadre of Firearms Silver Commanders is developed for managing all firearms incidents.

Recommendation 14: It is recommended that consideration is given to replacing the officers who commence command of an incident where their training and experience is insufficient for the complexity of the case. In the early stages of a spontaneous incident, it is recommended that the officer fulfilling the role of Silver should exercise command over all officers involved, including responsibility for armed officers. This should only change if there is a system of designated Firearms Silver Commanders who subsequently and explicitly adopt this role.

Police Complaints Authority 81 1.9 (iii) The role of the Bronze Commander An effective Firearms Bronze Command was identified in nine of 24 incidents, including four pre-planned operations. The remaining five spontaneous incidents were primarily those that became a siege or a prolonged confrontation affording the time to establish a command structure. In other words, Bronze Command was least visible and least effective in spontaneous incidents of short duration. In nine incidents it was not possible to identify an individual who fulfilled the role of Firearms Bronze, which were all spontaneous incidents and, with one exception, they were concluded less than 20 minutes after armed officers were called.

In three incidents, more than one individual acted as Firearms Bronze on what appeared to be an ad hoc basis. In the opinion of the PCA advisor, at least one of these self-selected Bronze Commanders contributed to the incident outcome by suggesting a proactive tactic based on little evidence. SIOs or the PCA advisor considered that Firearms Bronze was ineffective in eight of the 24 incidents (33%).

Case study four: The adequacy of Bronze supervision

In one incident an armed constable reported that: “throughout the whole incident, I didn’t receive any direct supervision. This is not unusual, and is not a problem as in my experience we are left very much to decide what to do between ourselves, with us requesting advice and information or direction as and when required”. It is interesting to note that this comment was not meant as a criticism of supervisors. Also, in the opinion of the PCA advisor, the most successful Bronze Commanders in the review cases were trained supervisors.

Recommendation 15: It is recommended that Chief Officers ensure that trained supervisors or nominated officers carry out the role of Bronze Command. Firearms Bronze Commanders should have no other role in the incident – in other words, it is not appropriate for them to take on additionally the role of firearms officer, negotiator or Tactical Advisor while also acting as the Bronze Commander.

The lack of Bronze Command of armed officers was a common theme across a number of incidents. While this was not set up because of time restraints in four incidents, in three others there were failures relating to the location of the Bronze Commander, the role they adopted in the incident and the lack of supervision, all resulting in an absence of viable Bronze Command. Where a group of constables were dealing with an incident, Bronze Command decisions were often taken by different officers at different times. The result of this was that no one could be identified as Bronze; there was no consistent progress of one tactic and even if something went wrong, no one could be considered responsible.

82 Police Complaints Authority Recommendation 16: It is recommended that the dispatch of supervisors to the scene to act as Bronze Firearms should be considered critical for the resolution of firearms incidents. It is recommended that where supervisors are not available immediately, a nominated team leader should act as Bronze on at least a temporary basis, so that there is a nominated Firearms Bronze Commander at all times in every firearms incident.

However, even when supervisors were at the scene, there was frequently little evidence of them exercising command or control of the armed officers’ actions, behaviour or planning. In five incidents, there was no evidence of supervision of the armed officers involved in the incident, in two more the Silver Commander was passive, in two the Silver Commander was either not suitably trained or did not know the force policy. Similarly, issues arose with the tactical advice in two cases – one where the advice was ignored and one where no tactical advice was given.

Often they concerned themselves with peripheral and logistical matters rather than focusing on the confrontation between armed police and the suspect. Many investigators commented on the expectations placed on supervisors to fulfil several roles creating demands that individuals could not meet. In some forces it is a matter of policy to expect the supervisor who should act as Firearms Bronze also to be the Tactical Advisor and an armed officer. In other incidents supervisors had to attempt to fulfil several roles because insufficient resources were sent to the scene.

In some incidents the supervisor was also an authorised firearms officer and decided to respond to a spontaneous incident in the role of the armed first responder. This resulted in there being no Firearms Bronze Command, with no attempt made to call other supervisors to provide Firearms Bronze Command or other armed officers to relieve the supervisor even though the incident duration could not be known. Armed officers are generally experienced, competent and well trained for this role, but they require supervision and instruction, and the role of the Bronze Commander is critical in providing this.

1.10 Operational behaviour and organisational culture The operational behaviour of the majority of officers involved in the incidents in the review cases was appropriate, professional and often included considerable personal risk. However there were examples where the attitude and behaviour of some officers raised concerns about the culture that prevails among some firearms officers.

Police Complaints Authority 83 Case study five: culture – drinking the night before an operation

In one pre-planned incident an officer was briefed the previous evening and made aware that there would be an early morning start. Despite this he consumed several alcoholic drinks – a significant breach of national guidance. The inappropriate behaviour was compounded by the fact that prior to being issued with a firearm the officer was not asked by any supervisor if he had consumed alcohol nor did he declare it. The incident came to light during the investigation although the officer did not discharge a firearm.

In the above case, it was fortunate that this officer was not involved in the actual shooting but his action may be indicative of deeper problems with safety compliance that should be regarded as a crucial ‘ancillary’ matter for unit managers to deal with either by altering procedures (such as breathalysing all armed firearms officers before operations) or increasing the severity of action taken against identified transgressors. The second case may be indicative of a more generic attitudinal problem relating to the use of force in seeking to resolve incidents in a timely and effective manner.

Case study six: Firearms unit culture – use of excessive force

In a spontaneous incident, an officer engaged in actions which resulted in considerable damage to a suspect’s property. According to his account, the damage was accidentally caused rather than resulting from deliberate use of excessive force. However, this account does not accord with the tactic deployed or with the location the officer must have been in to carry out other actions that are substantiated as his. Whatever the actual cause of the damage, any wrongdoing is compounded by the apparent intention of the officer to conceal the event. Other witnesses including police officers described the incident in a way inconsistent with the officer’s account. The officer did not discharge a firearm and was not one whose actions were closely scrutinised in the investigation. However, such actions or their attempted concealment do not reflect positively on the police.

To these incidents could be added others in which officers failed to make the IOs aware of documents that were material evidence and a reluctance by officers to give a full and detailed account of events, especially during interview. There is a significant issue around credibility that, while the specific issues may be relatively minor, will have a potential impact on the credibility of both the firearms officers and the post-incident investigation.

Recommendation 17: Chief Officers should be aware of cultural issues that may have an adverse impact on the professionalism of firearms units and address them effectively.

84 Police Complaints Authority The influence that managers have on the culture, attitude and operational behaviour of firearms units should not be underestimated, as they select officers, decide who should stay and for how long, and control training and equipment procurement. To reflect the significant position that managers of firearms units hold, it may be appropriate to review the culture, attitude and operational behaviour of the firearms unit and their influence on it following a shooting by police. In at least one of the incidents, there were suggestions that the dominant culture in the firearms unit had an adverse effect on the professionalism and conduct of the officers.

Similarly, issues of professionalism can arise from the consequences of team culture. Some firearms units use nicknames that do not convey a professional image or are grossly offensive. While it may be impossible to prevent officers adopting a nickname they should not be allowed to use operationally any nickname that, if publicly known, would bring the police service into disrepute.

Recommendation 18: Chief Officers should ensure that, if firearms officers commonly use nicknames in their operational work, these names do not have offensive meanings or connotations and that use of offensive nicknames is regarded as discreditable conduct.

1.11 Additional management issues 1.11 (i) The recording of authorisation and other decisions The process of authorisation to enable firearms to be issued to an officer was not always documented, meaning that the investigation has been hampered by the absence of an accurate record of what strategic options or alternative tactics had been considered by authorising officers. In one fatal shooting, the authorisation process was poorly documented; in another fatal case there was no documentation of contact with the Silver Commander, and in two other cases either the Gold or the Silver Commander did not appear to have authorised the operation. In a further case, the Gold Commander did not authorise (because he wanted questions answered), the Silver was unclear as to what was required of the armed officers, and no documentation was prepared for any part of the operation. It is critical that, given the risks associated with firearms operations, and as a result of public concerns about the police use of firearms, comprehensive documentation is prepared and retained.

Recommendation 19: It is recommended that Gold and Silver Commanders should be able to demonstrate rigour in their decision taking, and the adequacy and consistency of the recording of this information should be evaluated by each force and reviewed by the Chief Officer. It is further recommended that only duty inspectors who have completed the firearms command course should adopt the Firearms Silver Command role.

Police Complaints Authority 85 1.11 (ii) The role of control rooms in managing firearms incidents The impact of the control room varied in both style and competence in the firearms incidents included in the review. In some forces the Inspector in charge of the control room was clearly the Silver Commander until the local supervisor took over. In others, the control room appeared to act as a switchboard passing details from one officer to another. The quality of the information that was sought on behalf of the armed officers and the support provided also varied. In some incidents it was the armed officers who initiated requests for information and support during their travel to the scene.

Recommendation 20: It is recommended that control room staff receive appropriate training to enable them to provide prompts to officers attending incidents, seek standard information on behalf of the armed officers and initiate the provision of supporting resources for officers attending the scene. Only officers who have received appropriate training in the management of firearms incidents should be involved in this critical role within the control room.

1.11(iii) Equipment issued to firearms officers Force policies about the recording of equipment issue should be rigorously maintained. There were a number of incidents where weapons, ammunition and equipment were not booked out accurately. The most serious consequences could be that officers could be investigated for a conspiracy to pervert the course of justice. Additionally it reduces confidence in the police when these lapses become public and can raise a question over an otherwise competent operation.

Recommendation 21: ACPO should review the methods used for recording the booking out of weapons, ammunition and other firearms equipment.

1.11 (iv) Incident volume and the unique circumstances of the MPS Of the 24 cases in the review, 11 occurred in the MPS area of which four were fatal – representing 46% of the shootings included in the review. To assess whether this apparent disproportionality was consistent over time, all police shootings over a longer period were also considered. Between the start of 1991 and the end of 2001, the PCA has supervised 66 shootings causing injury or death, of which 34 (52%) have been in the Metropolitan Police area. This difference is statistically significant11 as there is less than a one in one thousand likelihood that this is a chance finding, suggesting a consistently higher rate of shootings in the MPS area. As a result of the low numbers of shootings in other Home Office police forces, no equivalent assessment is possible, either for the period of the review or for the full 10-year period.

11 χ2 = 22.2, df = 1, p < 0.001

86 Police Complaints Authority However, this statistical evidence is not the only justification for focusing on the MPS as case analyses carried out by the PCA firearms adviser prompted further issues relating to the practices employed in resolving these cases. To make sense of what appears to be a disproportionate rate of shootings in the MPS, two possible explanations need to be considered:

1. Unique social and cultural factors that make shootings more likely to occur in London; 2. Differences in police methods that mean shots are more likely to be discharged in firearms incidents in which the MPS are involved.

In addition to being the largest police force in England and Wales, London is also differentiated by its status as a capital city with unusual policing demands generated by the tourist, commuting and itinerant population, and by the sheer size of its population. In their submission to the review, the MPS have suggested that the disproportionality is a result of the unique context in which they operate, particularly the elevated rates of violent crime reported in the MPS area. There is supporting evidence from the British Crime Survey (2002) to suggest that violent crime rates are higher in London than elsewhere in the country.

In an attempt to enumerate some of these factors, using data gathered from the British Crime Survey, Her Majesty’s Inspectors of Constabulary and from the Office of National Statistics, the authors have compiled a table in which rates of police shootings in the period of review are assessed against baseline information to try to make sense of the basic disproportionality indicated by the percentage of shootings in the MPS in both the four and 10 year periods outlined at the start of this section.

Table 9: Rates of shootings as a function of relevant demographic factors comparing the MPS and other forces in England and Wales

Number of shootings per MPS (n=11) Other forces in Odds ratio England and Wales (n=13) 1,000 firearms incidents 1.1 0.4 2.9: 1 1,000 officers employed by force 0.4 0.1 4.0:1 1,000 firearms officers employed 5.6 3.0 1.9: 1 1,000,000 members of the general population 1.5 0.3 5.0: 1 1,000 violent crimes 2001-2002 0.07 0.03 2.3:1 1,000 diagnosed psychotic cases 0.38 0.06 6.3:1

Police Complaints Authority 87 Thus, while there are marked variations in the odds ratios calculated (between 1.9 times and 6.3 times) all of the indicators used would suggest that firearms discharges are significantly more likely to occur in London that in the rest of England and Wales, and that this difference is not a consequence of responding to more incidents, to differences in the overall population rates, or in reported levels of violent crimes or the size of special populations.

To examine whether the disparity in case frequency was a consequence of a broader location effect, rates of shootings as a function of incident deployments (based on data returns by forces to HMIC) were made comparing the MPS to other police forces based in metropolitan areas, to assess for the presence of a specific ‘urban’ effect (see Table 10 below):

Table 10: Police shootings per 1,000 firearms operations in the MPS and other metropolitan forces

Number of shootings per …. MPS (n=11) Other metropolitan forces (n=5) Odds ratio 1,000 firearms operations 1.10 0.38 2.9:1

This analysis does not support the suggestion that the disproportionality is a consequence of the demands or circumstances of ‘urban policing’, rather indicating that the effect is primarily related to the MPS alone, and may result from the choice of tactics employed in London.

Therefore, the second suggestion – that there are differences in the firearms response in the MPS – merits further consideration. There were indications from the expert analysis of certain MPS cases that the resolution methods employed in certain incidents may have involved ‘proactive tactics’ that were not employed in other forces in the reviewed cases (case studies eight and nine).

Case study eight: Use of ‘limited entry’ by SO19

In one case the plan selected was for ‘Limited Entry’, which involved smashing open the door of the premises to “control the hall and prevent movement through the house”. The officer described this plan as “the one most commonly used when the objective is to arrest an offender who is inside normal residential property” by SO19. However, there are no examples of other forces using this method within the cases in the review. This is the most proactive tactic available and may be used because it is quicker than the tactic used elsewhere which is to “contain and negotiate”.

88 Police Complaints Authority The evidence of proactive methods from cases studies is supplemented by one of the investigating officers’ comments, in his report on a case in the MPS area. The SIO concluded that “the tactic involved of a proactive strike has a degree of danger for the officers and conflicts with the basic premise of not advancing on an armed person. In the circumstances presented I believe that challenging the suspects from a position of cover would have been preferable”. The inference here is that proactive methods may lead to an increased likelihood of the discharge of a police weapon and may also permit less time for the consideration of alternative tactics or the deployment of additional resources, including police dogs or police negotiators.

Among the 11 MPS cases, there is evidence that ‘proactive’ methods have been used in five (45.5%) of the cases (two involving ‘limited entry’ to premises, one the use of hard stop tactics and two involving immediate challenges), while there is only clear indication of similar methods in one of the 13 cases that takes place outside the MPS area (7.7%). One of these cases is summarised in case study 9 below:

Case study nine: Use of ‘limited entry’ by SO19

The option put forward by the Tactical Advisor (also the Firearms Bronze and the supervisor for SO19) in one of the MPS cases to arrest suspects was not to contain the premises and negotiate but to use limited entry. This is an example where the most proactive option was selected partly as a result of the need for a quick resolution to release officers for other potential commitments. This may have implications for the safe resolution of the incident and may have increased the risk of a shooting taking place as happened in this case.

In our view, the analysis above indicates that there are five cases where proactive methods have been employed, which are likely to have contributed to the disproportionally high rate of shootings in the MPS area, both in the period of the review and across a longer time period. These cases provide a unique learning opportunity not only for the MPS, but for other forces and for the police management organisations (ACPO, HMIC and the Home Office). We are anxious to see that the learning opportunities from these cases are addressed satisfactorily.

There are weaknesses in the data that we have used in this analysis that result from poor use of evaluation and research into police shootings – an issue we propose should be addressed in Recommendation 1. Furthermore, the above conclusions necessitate a specific focus for the MPS area, as does the paucity of information on cases in which shots were not fired (including outcomes); cases where shots were fired at the police but not returned; and evidence on the relationship between the tactics employed and the outcome.

Police Complaints Authority 89 Recommendation 22: The Commissioner of the Metropolitan Police Service, the Metropolitan Police Authority and the Home Office should jointly commission a review of tactical options in the MPS including a data-based research study investigating the relationship between firearms tactics and outcomes in the MPS. The research component of the review, which should be undertaken as soon as possible, should have the following terms of reference:

1. A systematic analysis of firearms deployments in the MPS between 1998 and 2001, including data on reason for the operation, resources deployed, resources utilised, incident outcome and subsequent events (eg disciplinary action resulting). 2. The review should examine any differences in any of the above factors as a consequence of the location of the shooting and the characteristics of the suspect (including ethnic status but focusing on vulnerability resulting from substance use or mental health issues). 3. An analysis of the data collection procedures used within SO19, the accuracy of data returns to HMIC and methods of dissemination for lessons to be learned and for identifying ‘near misses’ and learning from them. 4. The review should a) reach conclusions on the lessons to be learned, b) make appropriate recommendations for future policy and practice and c) be published.

1.12 Training of firearms officers and training records The quality of firearms training was a major concern for staff associations and for victims’ families and their representatives. The evidence would suggest that not enough time was spent on training armed officers. Training objectives should be expressed as standards, the achievement of which is an absolute requirement. Standards should be set nationally and subject to external scrutiny to increase confidence that they are appropriate.

Recommendation 23: It is recommended that a review is conducted by The Police Skills and Standards Organisation to establish the standards required for armed officers to be considered competent, and that the implementation of standards should be subject to periodic review by HMIC.

Authorised Firearms Officers’ training records did not always provide the detail that was required to establish that they had been appropriately trained. The probability is that they had received the necessary training but poor record keeping and poor quality of detail provided opportunities for speculation.

Recommendation 24: It is recommended that the requirement to record accurately training records should be a duty on instructors and training managers, and failure should be considered a discipline offence. This process should be overseen by the Chief Officer and subject to scrutiny by the police authority.

90 Police Complaints Authority Overview of firearms management issues It is not unusual that Authorised Firearms Officers have their authority to carry firearms temporarily removed for reasons such as failure to reach standards set in training, following incidents and for personal reasons. The decision process to remove authority was well documented and appropriate action appeared to be taken. However, records of the change of circumstances which made it appropriate for the officer to be re-authorised were much less common. These decisions are often difficult with conflicting pressures on the managers making them. They could become significant if it was to be alleged that an officer involved in a shooting incident should not have been re-authorised.

The authors would readily acknowledge that the tactics and management used in firearms incidents have been largely successful in creating such a low rate of serious injury or fatal shootings of members of the public. However, the issues outlined above suggest that, in spite of such a high success rate, there are a number of issues that need to be resolved and the resolution of which may further reduce the unnecessary use of deadly force, particularly in instances where proactive methods are used with vulnerable populations. Furthermore, the increases in consistency of method and policy recommended would significantly enhance public confidence in what is already a generally effective method of minimising the unnecessary use of police firearms.

2. Availability and use of less lethal options and existing alternative tactics 2.1 The use of police dogs in firearms operations Police dogs are a key resource that can be used across a range of incidents and are frequently cited as tactical options for firearms incidents, although their use is restricted by what they have been trained to do. Passive attack dogs (also known as ‘non-compliant’ dogs) can be trained to attack individuals nominated by their handlers irrespective of what the individual is doing at the time, which is not the case for ‘general purpose’ police dogs.

However, in many of the incidents, there was no dog available and there was no incident in the review in which ‘passive attack dogs’ were deployed. In only three of the incidents was there an attempt to engage the dog – in one case, the dog did not engage a passive subject, in another the dog could not distinguish between the officer and the suspect and in the third, the dog was distracted by a noise and stopped before reaching the suspect. In a further eight incidents, police dogs were available at the scene but were not actively engaged, while in the remaining incidents dogs were either not requested or had not reached the scene by the time of the shooting. As a result of the HRA, the use of passive attack dogs has been reviewed by the Police Dog Working Group whose conclusions will be circulated shortly.

In the cases covered in the review, the availability and effectiveness of standard police dogs varied markedly. Even when deployed, they were not always able to be used in attempts at resolution of the incident. In one, the dog handler could not release the dog because the suspect was quiet and stationary, while armed officers were challenging him loudly and so

Police Complaints Authority 91 the dog’s attention was attracted to the officers rather than to the suspect, as would be anticipated with general purpose dogs. In another incident, the dog was distracted by a loud noise and was unable to intervene, while in several incidents a police dog was not available, often because they were not called early enough or there was no record of them being considered. Another issue was that, because the dog handler was not armed, the dog could not get close enough to the incident to become involved and so was unable to be included as a viable option.

The principle that the presence of police dogs was beneficial to attempts to peacefully resolve firearms incidents was challenged in one SIO report. A police dog trainer claimed that the presence of police dogs could aggravate the situation. While this is the personal opinion of one operational officer, the officers in a number of incidents did not express confidence in the effectiveness of police dogs in armed incidents, although views on this issue varied between incidents. However, the confidence of firearms officers in dogs would be improved considerably if police dogs were trained appropriately and deployed effectively in firearms incidents.

Case study 10: SIO recommendation about the use of dogs in firearms incidents

One incident involved a man running through the streets near his home naked to the waist, with a bottle of alcohol in one hand and a gun in the other, threatening police and public. In this case, the SIO reported that: “This remains an ongoing education process for those staff that will be involved in a firearms incident to ensure that the services of one [a dog] is requested at the earliest opportunity. Consideration may wish to be given to developing a policy that on deployment of an ARV to a likely firearms incident, a dog is automatically requested at the same time.”

The presence of a police dog may be perceived to add to the options available to the Silver Commander. The cases reviewed do not demonstrate consistency in police perceptions of dog use nor do they indicate the effective operational integration of the use of general purpose dogs in firearms incidents. However, in a number of cases, dogs were successfully deployed to the scene of incidents and, while they were not instrumental in incident resolution, this increased the tactical options available to the incident commanders.

Recommendation 25: It is recommended that Chief Officers ensure that when an ARV is deployed immediate consideration is given to the dispatch of an appropriately trained police dog and handler. ACPO should consider the development of a joint training package for firearms units and police dog handlers.

The limitations identified by the SIOs relating to the use of general purpose police dogs in firearms incidents need to be considered by forces and clear guidance disseminated to

92 Police Complaints Authority the firearms operational staff and managers. In addition to the operational difficulties of deploying dogs, there are also animal welfare issues to be taken into consideration in using police dogs to tackle armed suspects, an issue that has attracted recent media attention.

There are, however, two points that should be made in this respect. The first is that the majority of suspects in the current review were not in possession of real weapons capable of firing live ammunition and so the greatest risk to the animals may have come from the four individuals with edged weapons or the seven with shotguns or air weapons. In other words, in more than half of the incidents in the last four years, there was no greater risk to dogs than in any other operations. The second point is that the police officer may have to make a judgement about the relative risks to human life (not only that of the suspect but also for police officers and members of the public) in assessing the risk to the dog.

Furthermore, as a result of the problems identified, police forces may wish to consider the viability of using dedicated passive attack dogs in cases with non-compliant suspects. While general purpose dogs who have received additional firearms training are still likely to be attracted to sources of movement and noise, this is less likely to happen with specifically trained passive attack dogs. However, the use of such dogs is restricted by two factors. First, the unpredictability of the behaviour of even the most highly trained dogs means that the outcomes cannot be predicted with confidence, particularly in built-up areas with many distracting factors. Secondly, the circumstances under which dogs can be used are limited by the location of the suspect and the presence of bystanders or hostages. However, without the use of specifically trained dogs integrated within the firearms units, the effectiveness of the deployment of dogs in firearms incidents is likely to remain limited. At the very least, firearms managers should review their policies for utilising police dogs and conduct systematic evaluations of the effectiveness of such deployments in firearms incidents (ie not restricted to those that result in shootings).

Recommendation 26: Chief Officers should, as a matter of urgency, review the operational rationale for the use of police dogs in firearms incidents and consider the training and development issues that will result from such a review. Consideration should be given to the use of passive attack dogs in firearms operations even if, as a result of resource concerns, they have to be shared by several forces. This process should be overseen by ACPO.

2.2 Other ‘Less Lethal’ options There was evidence of the need for less lethal options to be made available at the earliest opportunity. It must be understood that there is no such thing as a risk free option available to police to resolve life-threatening incidents, nor can it be assumed that the less lethal option will be immediately effective in removing the threat. Less lethal weapons are an essential element in the basket of options which should be available to police, but in some incidents it is likely that the police will initiate the use of less lethal weapons long before they would consider using conventional firearms.

Police Complaints Authority 93 There are three main concerns with the use of the so-called ‘less lethal’ options available to the police:

1. Technical issues of impact and effectiveness (which will include questions about where and when they can be used, and the possible adverse outcomes, particularly to vulnerable populations associated with their use). 2. Criterion shift concerns – there are concerns that the availability of less lethal options may result in a lower threshold for use so that the use of traditional firearms will not be reduced but will merely be supplemented by the less lethal options, as the less lethal options will be used earlier in incidents and that, in cases where there is a clear threat to life, the traditional firearm will still be used as the first option. 3. Issues around their application – which will include practical questions such as training and availability, but also concerns that, in many circumstances, less lethal options will be inappropriate. Thus, for instance, it has been argued that baton guns are not appropriate for use against individuals with live firing guns, although the appropriate circumstances for use remain under consideration.

Had they been available, it may have been possible to use one option from the following: dog, water cannon, baton gun or in three of the edged weapon incidents and their use may also have been possible in a further 11 of the 24 incidents included in the review. However, safety trials have meant that it has not been possible to introduce a number of these options yet and their introduction will require considerable preparation, assessment and training. The National Schizophrenia Fellowship were concerned that the special needs of people with a mental illness should be considered as ‘less lethal’ alternatives are developed.

According to current ACPO guidelines (circular 31/2001), baton guns are not intended to be a replacement for conventional firearms. Furthermore, the tactical deployment of baton guns “must include the deployment of additional officers, in possession of conventional firearms, in support of the baton gun officers”.

The inevitable caution that surrounds the introduction of new technologies as ‘less lethal’ options has meant that there has been considerable time expended in the evaluation and review of options conducted by PSDB and which are summarised in the report “Less Lethal Options” (Donnelly, 2001). The report recommends that “Before any of the less lethal technologies and devices are used by the police in the UK, it is strongly recommended that they are subject to a full and thorough evaluation, including an assessment of the medical aspects of using such a device” (Donnelly, 2001).

The report examines the current evidence base for a number of options grouped under the headings of ‘Impact Devices or Kinetic Energy Rounds’, ‘Long Range Chemical Delivery Devices’, ‘Water Cannon’, ‘Electrical Devices’ and ‘Distraction/Disorientation Devices’. Although baton guns have now been introduced by a number of forces, the tests on safe distances for use had not been completed at the time of writing.

94 Police Complaints Authority As part of the ‘multiple hurdle’ research strategy employed by PSDB, in which a wide range of options were initially tested and each option retained for future testing on the basis of their performance, poor performance in testing has led to the rejection of all square and rectangular bean bags and multiple ball rounds.

Among the other options that have been widely discussed is the Taser, an electrical device that propels a pair of barbed darts attached to two trailing wires which, once attached to the suspect, will release an electric current through the subject’s body. This provokes involuntary muscle spasms and loss of motor control, but is restricted by the fact that its maximum range is 21 feet, which means that it could only have been used in a small number of the included cases. Furthermore, Donnelly reported that trials have shown effectiveness rates of between 50 and 85% and that “focused individuals were able to fight through the effects of the electricity and could continue with an attack” (p28). In 356 operational uses of the Taser in the United States, it has not worked in 38 (10.7%) cases.

Other options that were considered were nets and wire entanglement systems but these were rejected on the grounds that they were ineffective and that suspects were able to tear through the nets. Similarly, trials of stun guns and glue and foam were discontinued because of the problems of decontamination and the fears of suffocation. As a result of this work five types of device have been advanced for further testing – impact devices, long-range chemical delivery devices, water cannon, electrical devices (particularly the Taser) and distraction/disorientation devices. Once tests assessing further operational aspects of effectiveness have been completed, each ‘successful’ method will be assessed by a medical committee. However, concerns will remain that this research strategy is taking too long and consideration must be given to ways of speeding up this process to ensure that the options available to Tactical Advisors and incident managers are maximised.

One concern expressed by several of the families was that the police were too quick to resort to traditional firearms. This will only be adequately addressed when a comprehensive package for less lethal alternatives is available to supplement the use of negotiators, police dogs and baton guns, and clear policy guidance is developed for their integration and use.

Four of the 24 cases in the review involved edged weapons and might possibly have been resolved with baton guns or other less lethal options. Indeed, in one of these cases, two officers had attempted to use their batons to effect an arrest under cover of their armed colleague. While not successful in this case, the attempt to use less lethal options, such as batons, CS spray or negotiation, as occurred in a number of the cases reviewed, should be regarded as positive indicators of a commitment to less lethal resolution. However, there is also a clear indication that the current less lethal options available are not being used to their full potential and that the failure to offer adequately trained passive attack dogs, or to provide skilled negotiators, is resulting in the discharge of traditional firearms at an earlier stage in some of the incidents reviewed than may have been necessary.

Police Complaints Authority 95 3. Containment and the speed of resolution The intention of containment by police, armed or unarmed, is to hold suspects where they are or, if this is not possible, at least to observe and report their movements. This is particularly important when the suspect is in a public place and appears to pose an immediate threat to life. However, there is a difference in what can be achieved by armed and unarmed officers. While armed officers have the ability to restrict the movements of suspects by the use of force if necessary, unarmed officers are more restricted in their ability to control the movements of suspects. Nonetheless, unarmed officers can reduce the risk to the public, police officers and the suspect by their attempts at isolating the suspect. In the review cases, there were several examples of unarmed officers preventing the suspect from escaping which had the double effect of reducing the risk to the public and facilitating the safe deployment of firearms officers.

Case study 11: Effective unarmed containment preventing the escape of the suspect and improving public safety

Unarmed officers responding to an armed crime identified the suspect and one officer gave chase on foot. The offender stopped and confronted the officer with a gun and ran away again, with the officer again following and alerting other officers that the suspect was in a public place, although such a response places the unarmed officer in considerable danger. The suspect was kept under observation and on the move, with his attention focused on the police. Other officers were able to warn members of the public who took refuge in shops and offices. The offender was unable to escape and unarmed officers were able to attempt to persuade him to surrender. He would not do so and, when challenged by armed officers, he aimed his gun at them and was shot.

Unarmed officers were the officers first attending in 12 of the incidents (half of review cases) and in six of these (quarter of review cases) were able to establish a containment. However, in seven other incidents the lack of effective containment may have had a detrimental effect on the outcome. The poor quality of unarmed containment was significant in a number of incidents. Armed officers in some instances were confronted with a confused and uncontrolled situation requiring them to react immediately because of the risk to public and police. Consideration should be given as to how unarmed containment can be improved to reduce the risk that armed officers will be required to make these critical decisions immediately on arrival. Central to this will be improving the capacity of unarmed officers to contain armed suspects and their ability to liaise with armed officers.

First responders often appeared ill-equipped to make appropriate decisions about containment and were not supported by supervisors in the vital early stages of the incidents. Indeed even when supervisors were present their decisions did not always appear to contribute much to containing the suspect. As a result of the importance of both unarmed and armed containment, and the failures evidenced in a number of the cases

96 Police Complaints Authority under review, it is critical that incident managers (in particular Silver and Bronze Commanders) are adequately trained and resourced to contain situations effectively.

Recommendation 27: It is recommended that protocols for unarmed containment are reviewed by Chief Officers, and this review should examine the training of unarmed officers in placing containments.

A further issue arises for cases that can be described as possible ‘provoked shootings’. In several of the incidents, incident management has been made problematic by the failures of containment when officers are faced with suspects who are both non-compliant and who are either indifferent to being shot or who are actively seeking this outcome. If such individuals do not actually point their weapons at people (and thus are not an immediate threat to life), but ignore police instructions, containments may rapidly be rendered ineffective as the individuals simply walk through them.

Case study 12: Failure of containment in a case of possible provoked shooting

In this case, the individual had been identified in the grounds of a psychiatric hospital where he had unsuccessfully attempted to be admitted. After an initial altercation with hospital staff, armed police arrived and contained a part of the hospital grounds. Although the suspect was identified and challenged to put down his weapon, he did not do so and walked through the police containment. The police containment became mobile but, because the suspect continued to move in the direction of a wooded area where he could not be contained, the decision was taken to attempt to stop him. This involved attempting to run him over in an ARV, which was not successful – when he got up after the collision, he aimed his weapon at an officer and was fatally shot.

Although there were clear grounds for believing the suspect in the above example was attempting to provoke a police shooting, there was no clear contingency plan in this case, or in at least one other case, for this breach of containment. The ACPO Manual of Guidance offers only the most cursory instruction – and six short lines of text – on dealing with provoked suicides. In the example above, the failure to account for non-compliance associated with suicidal intention led to the implementation of an ill-advised and unsuccessful ad hoc strategy. Given that as many as 11 of the 24 cases included in the review may contain elements that would indicate they are ‘victim-precipitated’, it is imperative that ACPO develop a more effective strategy for the identification and management of this situation.

Recommendation 28: The ACPO Firearms Manual should be amended to provide clear guidance for the containment and management of individuals who are armed and ignoring police instructions, as a function of indifference about whether they are shot.

Police Complaints Authority 97 B. CHARACTERISTICS OF THE INDIVIDUALS SHOT 4. Mental health issues/alcohol/illicit drugs 4.1 Mental health issues In many of the incidents, as has been reported by Burrows and in the international literature (eg Parent and Verdun-Jones, 1999), an individual with mental health problems had access to real or imitation guns, or had other dangerous weapons. Such incidents were rendered more volatile because the individual failed to comply with police attempts to get them to put down the weapon, appearing not to understand the consequences of their actions. Their understanding was also often further affected by drugs, alcohol or both.

Although such individuals may require psychiatric assistance and may have had little voluntary control over their actions, they presented an immediate risk to the public and that was the focus of the police response. While the safety of the public must always be the focus of the police response, this should not be considered as incompatible with the well- being of the suspect. In one case, the individual shot made nine contacts with the police in the two weeks before the shooting in circumstances that indicated that he had mental health problems, which on two occasions were recorded as “harmless delusions” on the incident log. No referral to mental health services appears to have been made.

Recommendation 29: It is recommended that the response of police, health service and other agencies to people in mental health crisis that appear to be posing a threat to life is reviewed by Government. A working group involving the Home Office, the Department of Health, ACPO and relevant NGOs should be convened to address this issue.

Cases involving people with mental health problems in the review included a patient on an hour’s leave from a mental health unit in a hospital, several recently discharged from hospital care, some who were receiving out-patient treatment and others who had received other forms of treatment.

Many incidents were a spontaneous armed police response to suspects whose mental health history was unknown but whose behaviour indicated a mental crisis. Even in protracted incidents the level of co-ordination between the police and health and social services was considerably less than when the problem was physical health. Indeed, the legal representatives of one family felt that the police force had failed to seek adequate information on the mental health status of the suspect and that this hampered their ability to negotiate effectively.

Recommendation 30: It is recommended that the review proposed above examines how intelligence and information are used by armed and other officers dealing with a person in mental crisis apparently posing a threat to life, particularly around use of information and support from family members and carers.

98 Police Complaints Authority It should be noted that one of the main recommendations of the Burrows report was that firearms officers’ training should include mental health awareness and training in drug and alcohol issues. The report went on to recommend that professionals who work with these special populations have an input in the training of firearms officers and negotiators yet, to the extent that this has occurred, it has not been sufficient to address the ongoing problems with vulnerable individuals.

4.2 Recognition of mental illness While it is recognised that a number of forces are aware of this issue and have committed both time and resources to its review, the evidence from the cases presented here would suggest that this has not yet elicited an adequate strategy for the identification and management of such issues.

Recommendation 31: It is recommended that the training which firearms officers receive in mental health awareness issues should be reviewed to ensure that emphasis is placed on the recognition of irrational behaviour and its possible causes and that this recognition be used in the development of tactics for the management of the incident. This amendment to training content should be developed by each Chief Officer and overseen by the Police Training and Development Board.

5. Provoked shootings In as many as 11 of the 24 cases included in the review, there are behavioural indicators that some element of deliberate self-harm may have been involved. For several, this was linked to significant mental health problems, while the factors that led to this suicidal objective may also have included some combination of domestic disputes, alcohol or illicit drug consumption, and an interest in or obsession with firearms. In other words, their behaviour may have been rendered irrational by life stress factors that exacerbated pre- existing and underlying mental health problems such as depression or psychosis.

Case study 13: The combination of factors in victim-precipitated shootings

A young man who had previously been discharged from the army for disciplinary breaches, had been to a club with his partner where both had been drinking and argued about his girlfriend talking to another man. On returning home, the argument continued before he left the house with his air-rifle and engaged the police officers. In this case, although the suspect had a live weapon that was loaded, he did not fire at the officer, even after the police officer fired at him and missed. This may provoke speculation that he never intended to fire his weapon and that he was actually committing ‘suicide by cop’, particularly as the suspect himself phoned the police to alert them that there was an armed man in the area. However, the officers involved would not have known this at the time nor would they have been aware that he may have had suicidal intention.

Police Complaints Authority 99 While there were incidents in which suspects said to the officers things like “you want to shoot me, go ahead” or “you have come to shoot me, do it now”, there was no clear pattern to these incidents. This may reflect variations in incident dynamics, with alcohol-related incidents of this kind more likely to involve distorted perceptions and ‘dramatisations’ rather than the more clearly planned and intentional suicidal decisions of several of the incidents. It is interesting to note that, in four of the incidents, it was the suspect who phoned the police to let them know that there was an armed man at large, indicating their desire for a confrontation with armed police. Indeed, one of these individuals, case D, had previously expressed his intention of being shot to his partner.

It is not at all clear how such incidents can be prevented, particularly if such individuals are in possession of what appear to be real weapons in public places where there is an immediate risk to the armed officers or to the public. However, in the incidents in which alcohol or illicit drugs are known to be involved and the location is contained, as in two of the fatal incidents, the avoidance of tactics designed to produce an early resolution should be encouraged. It is likely that those whose self-harm intentions are fuelled by intoxication may be unlikely to escalate the risk once the substance effects wear off. Of the cases in the current review, two fatal shootings may have been avoided if such a situation had been successfully identified and the incidents had been ‘played long’, allowing the tensions to defuse and the effects of the alcohol consumed by the individuals involved to wear off. This, however, is not a panacea – in two other incidents resulting in fatalities, one of which involved an individual with diagnosed mental illness, incidents of long duration and prolonged attempts at negotiation did not prevent fatalities from occurring. Nonetheless, in situations in which the suspects are intoxicated, there may be more chance of preventing a police shooting when incidents are played long.

6. Need for multi-disciplinary teams and interventions In the majority of the spontaneous incidents included in the review, the resolution of the incident was complicated by the psychological state of the individual, whether this was the result of the short-term effect of alcohol or illicit drugs, or the more severe and enduring effect of mental illness or suicidal intention, or by some combination of these factors. These factors were also frequently compounded by life stresses, such as domestic disputes, and financial or job-related problems.

This creates two main problems for the police – the first is an inevitable lack of expertise in diagnosing and managing these problems and the second is the communication problems that subsequently result from the mistaken assumption of suspect rationality made by the police. The over-representation of ‘vulnerable’ individuals among those shot is likely to reflect their inability to make rational decisions when confronted by armed police, particularly if they have already formed the intention of being shot.

However, given the over-representation of mental health and addiction problems, firearms teams should increasingly shape their training and incident management strategies around the fact that those who are most likely to fail to comply in spontaneous incidents, and so be

100 Police Complaints Authority shot, are psychologically compromised. To do so effectively, an increased focus on multi- disciplinary team-working at each stage of the management process is likely to confer significant benefits.

While firearms officers are likely to benefit from improved basic ‘diagnostic’ skills to enable them to identify substance problems or mental illness, it would also be beneficial that other professionals are called to incidents where PNC checks or local intelligence identify such problems. In the same way that medical resources would automatically be requested for physical injuries, the predominance of mental health factors in the spontaneous police shootings would suggest that the most effective response to firearms incidents where such problems are identified will include local specialists in this area who should be contacted either in person or by telephone. The NHS Special Hospital or regional forensic services may have relevant expertise which could be made available at short notice.

In their submission to the review, the National Schizophrenia Fellowship advocated such a multi-agency approach to training firearms officers. They argued that there is a clear need for those experiencing severe mental illness to be treated differently from other members of the public by the police, particularly in this kind of life-threatening incident. Given the high proportion of police shootings in the period of the review that involve those experiencing mental illness, this leads to a conclusion that the development of specific protocols and working practices for this population are needed urgently.

Recommendation 32: ACPO should ensure that protocols for inter-agency agreements with local addiction and mental health services are developed to ensure that joint working arrangements can be reached for the identification of at-risk populations, and for the joint training of firearms officers and health professionals. The review of mental health issues proposed above include attempts at identifying and promulgating ‘good practice’ around the management of mental health related firearms incidents, and this should form the basis for the development of national standards.

It is also critical that as much information is gathered as possible about such factors from family members and partners who may not only be able to assist with diagnosis and provide the details of the relevant contacts in treatment services. They may also, within the bounds of safety, be best placed to assist in calming down the vulnerable individual and enabling a peaceful solution.

C. POST-INCIDENT ISSUES 7. Family issues and the adequacy of disclosure of information 7.1 Delays One of the major concerns expressed by families and by the representatives of officers concerned the effects of delays at various points in the process of investigating the incident and deciding on its outcomes. One of the side effects of the duration of the investigation is that considerable time can elapse before information is passed to families and the officers

Police Complaints Authority 101 affected. Because they do not feel that they are getting all of the information and that what they do get is so long in coming the family may feel that their involvement is marginal and their interests ignored.

The following table shows the time taken to reach key stages in the 20 cases reviewed where the investigation has been completed. The CPS can only make a decision on whether or not there are to be criminal proceedings after the PCA has issued its statutory statement under s. 73 of the Police Act 1996. It is likely to review its decision after an inquest has been held and in the light of the evidence heard. The PCA usually determines if there are to be disciplinary proceedings only after an inquest has been held. It must receive proposals from the relevant police force before being in a position to do so.

Table 11: Dates for the key events in the 20 cases in the review for which the investigation has been completed

Case Date Date of IO Date of PCA CPS Decision Date of Date of PCA Report Statutory Inquest Decision Statement Verdict Letter A 1998 02/12/98 04/01/99 31/03/99 – 31/08/01 B 1998 13/05/98 21/05/98 09/11/98 27/11/98 17/12/98 C 1998 07/06/99 29/06/99 18/04/00 – 08/06/00 D 1998 16/09/98 23/09/98 Not referred – 30/10/98 E 1998 24/09/99 24/11/99 17/1/00 – 03/03/00 F 1998* – G 1999 28/05/99 29/06/99 29/09/99 – 06/12/99 H 1999 06/08/99 23/08/99 29/12/99 09/08/00 22/08/01 J 1999 13/12/99 20/12/99 07/04/00 04/05/00 20/11/00 K 1999 25/02/00 27/04/00 09/06/00 – 31/07/00 L 1999 26/05/00 06/06/00 04/12/00 21/07/02 Not yet M 1999 22/09/00 08/12/00 19/01/01 – 06/04/01 N 1999 28/02/00 19/04/00 08/06/00 – 15/08/00 O 2000 24/04/01 22/05/01 11/12/01 – 05/07/02 P 2000 20/04/01 29/06/01 Not referred – 26/07/01 Q 2000 06/02/01 25/04/01 31/05/01 – 29/06/01 R 2000 18/05/01 22/06/01 25/10/01 02/05/02 Not yet S 2000 27/11/00 20/12/00 19/01/01 – 30/04/01 T 2000 01/03/01 30/05/01 19/06/01 18/04/02 17/09/02 U 2000 18/05/01 07/11/01 Not referred – 23/04/02

*There are two separate investigations in this case: although the investigation into the shooting was completed in 2001, the outcomes of the complaint have not been finalised. The information in the table shows that for investigations into fatal incidents, the shortest completed investigation was three months and the longest was just under 12 months, with the average time taken approximately seven months. For non-fatal incidents, the shortest time taken was two months and the longest was, a wholly atypical, 29 months. With these, the average time taken was around 10 months. The time it took the CPS to make its decision on criminal proceedings shows similar variation, though here, on average,

102 Police Complaints Authority decisions were taken faster in the non-fatal cases (an average of less than three months). Where the CPS is involved at an early stage in the investigation, it will be provided with copy evidence as this becomes available and may advise the investigation team, as necessary, on aspects of the inquiry. In these cases it will receive the final report at the same time as this is sent to the PCA.

For the investigating team, and those making decisions on the evidence, delay will be an unavoidable consequence of the depth of the investigation, reflecting necessary rigour and thoroughness. Such considerations may well explain why some investigations took much longer than others. The review, however, confirms that the timescale on some investigations has been extremely prolonged and it is no surprise if this has had a significant adverse effect on many of the individuals and organisations concerned. The officers involved need to know promptly if there are to be any criminal or disciplinary proceedings brought against them, while families wish to learn as soon as possible and as fully as possible what happened and if anyone was to blame, so that they are able to draw a line under the event.

There is also an operational policing dimension to the duration of investigations as officers involved in shootings are removed from operational firearms duties, stretching resources. However, respecting these competing interests has contributed to delays in some cases and there is no simple solution available that would reduce delays across cases.

7.1 (i) The role of the Crown Prosecution Service Where a family or next of kin is often bewildered and confused by roles and processes, there is a clear need for the role of the CPS to be explained to them. Investigations into fatal incidents should have early CPS involvement and the prosecution lawyer responsible may need to meet the family personally to explain their role directly and how long it will take. In any event, both the PCA supervising member and the SIO should satisfy themselves that the family have been clearly informed of the CPS role and the likely timescale for its decision-making.

Concern was also expressed about the time taken by the CPS to make a decision and about possible bias in CPS decision-making, although while families may have felt this favoured the police, this view was not shared by police representatives. Increased co- ordination and communication between the CPS and the principals involved in the case may help to ease anxieties and confusion, and this process should be jointly facilitated by the SIO and the PCA member.

Early involvement of the CPS in the investigation has the potential to reduce the time it takes to consider and finalise its decision on the case and ensure that its requirements are identified early and communicated to the investigation team before the investigation is completed.

Police Complaints Authority 103 7.1 (ii) Delays and the Police Complaints Authority Concern was expressed about the length of time taken for PCA supervised investigations to be completed, for the statutory statement to be provided by the Authority under s. 73 of the Police Act 1996 and for its decisions to be taken on disciplinary matters.

The difficulty for those awaiting such decisions following a fatal shooting is that when the various stages of investigation and adjudication are added together – viz. police investigation, PCA scrutiny, CPS consideration, criminal trial (if any), inquest, force consideration, PCA review and finalisation, discipline hearing (if any) – the whole process can extend to a very long period indeed without any one organisation ‘taking too long’.

Table 11 above provides information on 20 of the cases in the review. As explained above, supervised police investigations did greatly vary as to the time which they took to be completed. However, PCA scrutiny of the final report and its issue of a statutory statement was rarely delayed unduly. The review data also shows that the Authority is not routinely responsible for significant unexplained delays in finalising its decisions on discipline. The PCA are currently reviewing these time variations with a view to informing the work of the IPCC.

Recommendation 33: It is recommended that ACPO, the PCA, the CPS and Coroners, in the light of this review, examine their practice and procedures with a view to minimising delays without compromising the rigour and depth of scrutiny and investigation required in supervised investigations into shootings which cause death or injury.

7.2 Legal aid and financial support Family concerns about having their interests represented were compounded by the huge financial expense they faced in maintaining legal representation, with no assistance given to them in obtaining financial support. There was criticism that public funding for families was not routine but only provided in exceptional cases, and that information on obtaining such support was not readily provided by the police investigators or by the PCA.

Recommendation 34: It is recommended that families are made aware by the PCA supervising member of who to contact to receive help and advice about the provision of legal advice and support. It is recommended that the PCA revises its leaflet to provide more information for bereaved families explaining issues around who to contact for legal advice and other support as an interim measure, prior to the creation of the IPCC.

Case study 14: Payment of funeral expenses

A man was shot in his home by a firearms officer after he appeared at a window pointing a pistol at armed officers. The man’s weapon was discovered to be an unloaded Colt 1911 replica. The police force responsible offered to pay the costs of the man’s funeral and this offer was accepted by his family.

104 Police Complaints Authority Whether it is appropriate for the police to meet the funeral costs in incidents where the death was a result of police action is beyond the remit of this review. However it may be beneficial if forces consider the issue in advance to avoid confusion if such a request is made. Great distress has been caused to families and considerable damage done to their relationship with police over this issue.

Recommendation 35: It is recommended that forces should consider in advance a policy in relation to requests for them to meet funeral costs. ACPO and the APA should seek to promote jointly national guidelines to ensure that there is consistency on this issue across forces, so that whether funeral expenses are paid does not depend simply on where the victim was shot.

7.3 The responsibilities of the principal officers post-incident While the period after the shooting is highly traumatic for the victim, if still alive, and the families of those shot, it is also a very difficult period for the principal officers who are also likely to be distressed by the shooting. The experience of trauma is likely to be exacerbated by the fear that they may lose their livelihoods, concerns about criminal charges and by the intense scrutiny and investigation, all for what they would see as simply attempting to do their job to the best of their ability. As Parent and Verdun-Jones (2000) have pointed out, the post-incident period can result in psychological stress and life problems for firearms officers that can be prolonged and intense.

Against this, there is the responsibility on the officers to ensure that the investigation is supported and the facts of the incident established. Any attempt to preserve the anonymity of the officers means that this dilemma – for both the individual officer and for the SIO who attempts to reconcile the needs of the investigation with the welfare requirements of the principals – is rarely known to either family members or the general public. This has become a concern in relation to several aspects of post-incident management:

7.3 (i) Making of notes by officers The expectation that firearms officers will be asked to make notes immediately after a shooting raises legal and welfare considerations together with potential opportunities or difficulties for the investigation. Several SIOs argued that early notes of officers’ actions are critical to an investigation and that they should be made independently, and that this should happen immediately after an incident. The serving police officer is expected to account for his or her actions in this way. The reasons given for not producing notes immediately after an incident were usually based on medical or legal advice. Although it may be anticipated that the shooting officer(s) would be affected by an incident, there was concern, that in some areas of the country, there appeared to be a practice of all officers describing feelings of shock to an FME and so being declared unfit to provide notes immediately after the incident.

Police Complaints Authority 105 The guidance in the ACPO Manual states:

2.12 The making of notes 2.12.1 The removal of the officers from the scene at an early stage will provide those involved with a period of re-orientation and allow for the preparation of a summary of events.

2.12.2 Initial notes (e.g. pocket notebook, Incident Log pages for each officer, or a pro forma) should be made as soon as practicable, subject to any individual legal advice received to the contrary. The entry should be timed, dated and signed.

2.12.3 Any suggestion that any officer is unfit to make notes at the time should be verified by the officer being examined by a professionally qualified person who can independently certify to this fact.

While this provokes a concern that different rules are applied to police officers than to other witnesses and especially family members who are often interviewed immediately despite being highly distressed, there may be sound medical reasons in individual cases. If, however, many or most of the officers involved in police shootings experience such stress or trauma, then one must question the adequacy of the training and selection processes involved in their preparation for the role. Armed officers must in general retain a capacity to describe reliably stressful events for them to be able to fulfil the role expected of them, and to meet the public’s expectations of them.

From the perspective of the SIO, the importance of the officer’s statement cannot be known in advance. Its provision may be critical to the early development of the investigation and the securing of other evidence. Furthermore, any officers’ notes or statements that are considered significant to a criminal case would almost certainly be challenged by the defence at court as unreliable if they were made after a considerable delay. The legal and medical needs of the officers should remain a serious consideration, but these must be reconciled with officers’ legal and professional obligations. As the guidance is currently worded, where an officer obtains legal advice not to complete notes immediately, then it appears that this may justify not doing so. This conflicts with the officer’s duty to assist in the search for the truth.

Recommendation 36: It is recommended that ACPO, after consultation with police staff associations, revise the Firearms Manual guidance on the making of notes by principal officer(s)12 to limit the circumstances where notes are not required to be made only to where there is either clear evidence of medical unfitness to make notes or, for sound investigative reasons, the officer is not asked to do so. Officers other than principal officers should always be expected to complete notes if fit for continued duty. The manual should emphasise that there is a presumption that police officers are expected to assist in the search for the truth.

12 Defined as “those officers who have fired or whose actions have altered the course of events at the scene of the shooting incident”.

106 Police Complaints Authority 7.3 (ii) Officers giving ‘no comment’ interviews to investigators A similar area of SIO concern with ramifications for public confidence relates to the significant number of officers subject to investigation who, when interviewed post-incident, exercised their right not to answer questions put to them. Some police officers and their staff organisations were concerned about the delays in completing investigations yet contributed to these by hindering the progress of the investigators and their efforts to find out what happened.

In one MPS case, the interview of the firing officer did not take place until 10 months after the incident, as a result of annual leave, sick leave and the inability of the officer, his legal representative and the Police Federation Friend to find a suitable date. Even when the interview did finally take place, the officer handed over a written statement then replied “I have nothing further to add at this stage” to all of the questions posed by the IO. In another MPS case, one officer, who was the subject of a complaint although he was not the firing officer, provided a prepared statement and declined to answer any questions put to him. In three more MPS cases, there were also significant delays that occurred in the preparation of statements or notes as a result of sick leave for the firing officer or problems with the availability of the officer, his legal representative or the representative from the Police Federation.

While there is a legal right to refuse to answer questions, when police officers do so the impression is created in the minds of families and the general public that they may have something to hide. It is surprising that this happens since the results shown by this review suggest that there is little likelihood that criminal or disciplinary action will arise from an investigation. It appears that the police service loses in terms of public confidence and yet there appears little gain for individual officers. By s. 36 of the Police Reform Act 2002, the law can in the future be changed to permit a disciplinary tribunal to draw adverse inferences from a failure to mention a fact when questioned and the disciplinary caution would correspondingly change to reflect this.

Recommendation 37: It is recommended that the Home Office introduce as soon as possible regulations to change the disciplinary caution so as to encourage police officers to co-operate with investigations.

7.3 (iii) The tradition of group debriefs for principal officers Legal concerns were raised about group debriefs because they have the potential to contaminate evidence, as a consequence of time before notes are made, and because of the way debriefs were carried out by Post Incident Managers. Increasingly the practice is for solicitors representing individual officers to hold group debriefing sessions immediately after fatal shootings. ACPO guidance stresses “that initial witness accounts shall be recorded before a de-briefing of any kind, to avoid later suggestions of manipulated or rehearsed evidence” (para 2.60).

Recommendation 38: Supervisory officers should ensure, in management of staff post- incident, that officers comply with ACPO guidelines (See para. 2.60).

Police Complaints Authority 107 7.4 The role of the Senior Investigating Officer A critical role in ensuring that the concerns of the public and the rights and responsibilities of the families and principal officers are met rests in the investigation. There has been considerable concern around the identity and status of the investigating team, and particularly the SIO.

7.4 (i) Selection It appears that selection of the SIO is often based on availability rather than on any systematic criteria. In the cases included in the review, one fatal incident has been investigated internally by a senior detective while a non-fatal hand injury has been investigated by an external Assistant Chief Constable. This apparent inconsistency will often reflect the initial judgements made by the PCA member about the key issues and the terms of reference for the investigation. While it is the issue of investigation by the home or a neighbouring force that has caused most concern, the rank and experience of the SIO are likely to impact on the quality and effectiveness of the investigation. As a consequence, there should be clear and systematic criteria for the selection of the SIO for police shootings.

Recommendation 39: It is recommended that the PCA should agree with ACPO and HMIC criteria for the selection of SIOs for shootings by police and should consider the establishment of a cadre of specialist firearms SIOs.

There was concern expressed by the families that the investigating force could be geographically close to the force in which the incident occurred, leading to fears that senior police officers would know each other and that this would have an adverse effect on their objectivity. A similar concern was that SIOs had been drawn from forces that were under investigation as a result of a police shooting incident, whose own practice may be open to criticism. Further, individual officers under investigation as a result of a shooting by police should not be asked to provide advice, expert opinion or direction to other investigations.

Recommendation 40: It is recommended that the PCA supervising member, having discussed this matter with the SIO, discusses with the family any personal knowledge the investigators may have of officers involved in the case and how decisions on the selection of investigators are documented to try to increase the confidence of the family in the investigation.

7.4 (ii) Training The review found few examples of poor quality investigations although considerable difficulties did arise on occasion between the families and the SIO, and also between the SIO and officers involved in some of the incidents. The SIOs were all qualified and experienced investigators but, given the rarity of police shootings, few had previously been involved in such inquiries, making their management of such a complex and high-profile task especially difficult.

108 Police Complaints Authority The formation of a cadre of SIOs who could be provided with specialist training to benefit from the experiences of others involved in shooting investigations may be considered desirable. This has already been recognised and the ACPO Crime Committee in conjunction with Centrex, the national police training provider, have organised courses to create such a pool of investigators. However, specialist training and support services for investigating teams in this area requires consideration by both ACPO and by individual Chief Officers. While there may be resource implications that make this problematic at present, this is an issue that should be picked up by the IPCC in the selection and training of independent investigators who are likely to be investigating shooting incidents from April 2004.

7.4 (iii) Senior Investigating Officer’s Report The quality and type of information available to SIOs varied markedly across cases. For instance, where pre-planned incidents were video-recorded, this was of considerable benefit to the investigating officer. This variation was reflected in the final reports produced. Many of the issues raised in the Burrows Report about the quality and style of SIO reports on police shootings remain unresolved, with marked variations evident across the cases examined. It would facilitate both the structure of investigations and the subsequent analysis of information if a standard data reporting process was used and that this was incorporated within a standardised reporting form agreed by ACPO and endorsed by the PCA (possibly based on the pro forma used for this review and included as Appendix 2).

Recommendation 41: It is recommended that a standard style for Senior Investigators’ reports should be consistent with the format and style recommended in the PCA Supervision Manual.

7.4 (iv) The use of expert firearms advice by the SIO To increase public confidence in the investigation, firearms advisors, trainers and commanders from a force under investigation should not be used to advise the investigators on technical matters, as their role within the force may have contributed to the circumstances of the shooting. Similarly, internally investigated incidents can produce a conflict of interest if those providing expert input have been involved in the training of the officers involved in the shooting, or in the writing of the force policy. In three cases, there was no external advice, and in another the advice and opinion about the principal officer’s behaviour came from that force’s firearms instructors.

Police Complaints Authority 109 Case study 15: Erroneous conclusions from internal ‘expert’ advice

In a case that resulted in injury to an officer, possibly as a result of mistaken tactics, the internal commentators commended the officers on their actions, as the shooting resulted in a non-fatal injury to the suspect. However, it is more likely that the outcome resulted from poor shooting technique, with this commendation all the more unacceptable as the bullet over-penetrated and hit another police officer in the leg, at least in part because of mistakes made in the tactical management of the operation.

Recommendation 42: It is recommended that an internal SIO obtains independent advice on the actions of armed officers, the command, tactical advice, training and policy in relation to the police use of firearms from someone with relevant experience of such incidents. Similarly, where ‘expert’ advice is cited by investigators, the use of the term ‘expert’ should be supported by evidence of both professional qualification and relevant experience.

7.4 (v) Liaison between the investigators and the family Concern was expressed about the quality of the treatment of the bereaved. This began with the notification of the shooting to the bereaved family, and delay in identification of the body, and communicating this information to the family. However, this may also reflect family concern and feelings of frustration and exclusion resulting from lack of information and delays in obtaining whatever information they did receive.

The NGO Inquest raised a number of concerns about the information provided to families – specifically the SIO’s report which they felt should be disclosed before the inquest, while families were occasionally unsure what documents they actually had and what others existed, which reduced their confidence in the investigation.

Case study 16: Disclosure of Investigating Officer’s report and evidence

In a case involving a fatal shooting, the police force responded to the bereaved family’s request for information by disclosing to family members a copy of the Investigating Officer’s report and supporting forensic evidence which related to questions they had raised. The external force which had investigated the fatal shooting fully agreed with this disclosure.

110 Police Complaints Authority Recommendation 43: It is recommended that the family or their representative are advised what will be disclosed to them and when, and that a general approach of openness should be adopted as long as it is consistent with issues of witness safety, legal requirements and public interest. The Police Reform Act 2002 makes provision for the disclosure by investigators of information to complainants and next of kin and detailed regulations will supplement the new duties placed on the IPCC and the police service.

One specific disclosure issue that caused concern to families was around the reluctance of shooting investigators to release the names of the principal officers. The Manual of Guidance provides practical advice for SIOs around the concerns for officers’ safety and the policy guidance leans in favour of anonymity. SIOs should pass this information, and the reasons for it, to families.

The more general issue of family liaison and its adequacy also provoked a number of concerns. The role of the FLO is made difficult as a result of their dual role in supporting the family while also being a police officer in the investigation team. FLOs require appropriate briefing and need to develop an exit strategy.

Recommendation 44: The PCA should review its role in supervising family liaison in shooting incidents prior to the creation of the IPCC. It should consider the appointment of external family liaison to supplement or replace the police FLO in exceptional circumstances, as envisaged in the Family Liaison Strategy produced in 2000 by the ACPO Homicide Working Group on behalf of the Crime Committee. Clear protocols would be required establishing the relationship between the FLO and the SIO to ensure that the FLO was kept informed about progress in the investigation.

The aim of such an initiative should be to ensure that the family’s needs are acknowledged and addressed as quickly as possible. In the post-incident phase, the PCA is also likely to have a critical role in liaising between the key agencies involved and in ensuring that the family are kept informed of developments where this is deemed to be both safe and appropriate.

Recommendation 45: The PCA should review its co-ordinating and central liaison role with family members through each stage of the investigation process up to and beyond the coroner’s inquest, and should also review its role in liaising between the different agencies involved in the post-incident period, prior to the creation of the IPCC.

7.5 Discipline of officers There was criticism from one NGO at the lack of criminal or disciplinary charges brought against police officers following shooting incidents. In the 11 fatal cases, criminal charges were brought against officers in one, although the prosecutions did not result in a conviction. In these 11 cases, seven have gone to inquest, with four cases not heard at Coroner’s court. Six resulted in verdicts of lawful killing and one jury returned an open

Police Complaints Authority 111 verdict. For the 22 cases in which the CPS has made a decision, only one case resulted in a prosecution. In contrast, while there are five cases for which disciplinary decisions have yet to be taken, in four cases officers have been given advice, two of which also involved disciplinary hearings.

That no inquest jury returned an unlawful killing verdict in the cases reviewed does not automatically vindicate police action, with some families dissatisfied about the lack of convictions, compounded by the secrecy of the police disciplinary process. The explanations given about disciplinary actions to members of one family were misunderstood and were uninformative. The family wanted to know exact details of allegations and the implications this had for the officers – what officers did or failed to do, thereby understanding the impact they may have had on the incident. That this has arisen as a problem is linked to the status of a “complainant”. A family member or even next of kin is not considered to be entitled to such information unless he or she has made a complaint. Section 80 of the Police Act 1996 restricts the giving of information in these circumstances. The Police Reform Act 2002 will repeal this legislation and will impose a duty on the IPCC and the police to provide as much information to a next of kin as to a complainant.

Recommendation 46: It is recommended that the information that is given to all families about disciplinary proceedings involving police officers is reviewed by the PCA and ACPO.

As was offered in one of the cases, forces involved in fatal shootings may consider it appropriate to develop a policy on offering apologies to the family of the deceased. While this must be done on a ‘without prejudice’ basis, this may, as in the above case, help to ease community and family tensions and generate open communication between the force responsible and the family.

8. How well have lessons been learned from previous shootings? Investigations often produced recommendations which were accepted at Chief Officer level but did not appear to be reflected in the future operational behaviour of the force, compounded by the fact that there is no outside monitoring of forces’ response to the recommendations made by SIOs. While this can only apply directly to those forces that have more than one case (Devon and Cornwall, Merseyside and particularly the MPS with 11 cases), all forces should attempt to absorb the lessons from such rigorous investigations. It will be beneficial if the recommendations were also sent to HMIC for them to monitor implementation.

112 Police Complaints Authority A number of the issues raised in the report reflect recommendations made by investigators in their final reports which would not appear to have been acted upon. These group primarily around training, tactics and command, with the concerns raised including: • Role confusion between Gold and Silver Commanders; • Uncertainty about the role of the Tactical Advisor and where this fits into the chain of command; • Review of policy on the role of Acting Inspectors in firearms incidents; • Review of the role of the control room in managing incidents and providing adequate resources; • The use of ‘proactive strikes’ and the decision-making process for non-compliant stops; and • The role of unarmed officers in establishing and maintaining containments.

These comments are drawn from four cases involving forces with more than one incident in the period of the review. Further recommendations from forces with only one incident in the review that have not been addressed by other forces relate to the development of a general policy on the use of dogs, the development of call-out systems for negotiators and the need for firearms officers to have better understanding of addiction and mental health issues.

Recommendation 47: Recommendations made following an investigation should be passed to the Police Skills and Standards Organisation, to the APA for dissemination to relevant police authorities and to the “Learning the Lessons from Adverse Incidents Committee.” 13

Additionally the PCA should maintain details of the recommendations made by investigators to be included in the information passed to the investigator of any further incidents that force is involved in.

Recommendation 48: It is recommended that recommendations made after an investigation should be passed to the investigator of any future incident by the PCA for their information, and to be included in the terms of reference where applicable.

13 The Standing Committee to Learn Lessons from Adverse Incidents was established to review serious adverse incidents which occur within police forces in England and Wales; to identify good practice; to disseminate findings and recommendations and facilitate changes in the sharing of information within the police

Police Complaints Authority 113 Chapter Seven: Conclusion

While there are few cases in the current review where serious errors or disciplinary transgressions occurred, a number of cases reveal significant problems with the management and administration of firearms incidents, with the culture of firearms units, and with the methods of resolution used in a number of the incidents. The exceptionally low rate of police shootings is a significant endorsement of the philosophy of armed policing in England and Wales but this should not be taken to imply that there are no grounds for improvement.

The majority of incidents involved the spontaneous police shooting of individuals rendered vulnerable by alcohol, drugs, mental health problems, stress and/or suicidal ideation. This suggests that the method of resolution employed should be chosen with greater consideration of the needs of this group. As Burrows concluded, there are clear training needs arising from managing incidents involving vulnerable groups along with a need to develop more satisfactory co-ordination with relevant specialized health services. There is also a need to reconsider the tactics (particularly those proactive tactics geared to establishing early resolution) that may make such individuals especially vulnerable.

Similarly, the development of less lethal options – including both the application of existing tactical options such as negotiators and police dogs and the development of new technologies – must be addressed with the utmost urgency to ensure that the police response is consistent with the requirements of human rights legislation. Further, there are clearly identified issues in the post-incident period in which the co-ordination of the investigators with the PCA and the CPS needs to be improved to increase the inclusion of bereaved families. There is much in the review for those planning the future IPCC to take account of as new approaches to investigation are devised and introduced.

114 Police Complaints Authority References

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Police Complaints Authority 115 Horvath, F. (1987) The Police Use of Deadly Force: A Description of Selected Characteristics of Intrastate Incidents. Journal of Police Science and Administration, Vol. 15, 226-238.

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Milton, C. H., Hollock, J. S., Lardner, J. & Albrecht, G. L. (1977) Police Use of Deadly Force. Washington, DC: Police Foundation.

Parent, R. & Verdun-Jones, S. (1999) Deadly Force: Police Firearms Use in British Columbia. The Police Journal,Vol. LXXII No. 3, July-September 1999, 209-224.

Sherman, L. W. & Cohen, G. C. (1986) Citizens Killed by Big City Police, 1970-1984. Washington DC: Crime Control Institute.

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116 Police Complaints Authority Appendix 1: Review recommendations

GENERAL

Recommendation 1: The Home Office should commission and fund a programme of research into police shootings and their circumstances with the research programme decided jointly by ACPO, the police staff associations, PCA, the Home Office and PSDB.

COMMAND STRUCTURE AND MANAGEMENT OF INCIDENTS

Recommendation 2: It is recommended that Chief Officers ensure that unique, local tactics devised in their force should be referred to ACPO, with HMIC advised accordingly.

Recommendation 3: It is recommended that the Chief Officers should adopt the ACPO Manual of Guidance, noting any areas of intended non-compliance, and that the consistency of Chief Officer’s policy and the operational actions of the force based on the use of the Manual are reviewed. Chief Officers should advise their police authority of any departures from the Manual and the reasons for each.

Recommendation 4: It is recommended that firearms policy is included in the job description of a Chief Officer who should be held responsible for compliance by the force, and this should be subjected to scrutiny by the relevant police authority and HMIC.

Recommendation 5: The principle of using proactive resolution methods with individuals who are suspected, on the basis of intelligence or immediate evidence, to be mentally ill or under the influence of psychoactive substances requires urgent review and systematic monitoring and evaluation. Further, at the level of policy not incident, it is recommended that the selection of tactics should be reviewed by the Chief Officer responsible for firearms within each force to establish the justification required for the most proactive to be selected as first choice.

Recommendation 6: It is recommended that advice is obtained by ACPO from addiction and mental health professionals and from those with negotiating expertise on methods of approach and challenge, particularly in cases where the suspect is believed to be vulnerable, prior to the formulation or amendment of firearms policy.

Police Complaints Authority 117 Recommendation 7: ACPO must review the current practice of challenges including their rationale and consider alternative methods, styles and locations of challenging that may reduce the likelihood of weapon discharges, based on research commissioned by the Home Office.

Recommendation 8: It is recommended that Chief Officers should ensure that Tactical Advisors do not have other roles that would conflict with this crucial tactical role during the course of firearms incidents. Where the incident necessitates that the Tactical Advisor takes on another role, they must be replaced as Tactical Advisor as quickly as possible.

Recommendation 9: It is recommended that ACPO review policy and procedures for the deployment of negotiators, and that officers should neither abandon their own role as firearms officers nor take over this specialist function without suitable training and instruction.

Recommendation 10: It is essential that Gold Commanders should be informed as soon as possible that a firearms incident is taking place and that Gold Commanders set an initial strategy even if they require additional information to finalise this strategy.

Recommendation 11: It is imperative that the Chief Officer ensures that each nominated Gold Commander receives appropriate training and that they can demonstrate that they have had sufficient training to fulfil this strategic role.

Recommendation 12: It is recommended that Firearms Silver Commanders be selected, trained and assessed against core competencies. They should also re-qualify against these criteria at appropriate intervals to be agreed by ACPO.

Recommendation 13: It is recommended that those who are expected to command a firearms incident have received appropriate training. They should be notified immediately an incident occurs. Where practical, it is recommended that a cadre of Firearms Silver Commanders is developed for managing all firearms incidents.

Recommendation 14: It is recommended that consideration is given to replacing the officers who commence command of an incident where their training and experience is insufficient for the complexity of the case. In the early stages of a spontaneous incident, it is recommended that the officer fulfilling the role of Silver should exercise command over all officers involved, including responsibility for armed officers. This should only change if there is a system of designated Firearms Silver Commanders who subsequently and explicitly adopt this role.

118 Police Complaints Authority Recommendation 15: It is recommended that Chief Officers ensure that trained supervisors or nominated officers carry out the role of Bronze Command. Firearms Bronze Commanders should have no other role in the incident – in other words, it is not appropriate for them to take on additionally the role of firearms officer, negotiator or Tactical Advisor while also acting as the Bronze Commander.

Recommendation 16: It is recommended that the dispatch of supervisors to the scene to act as Bronze Firearms should be considered critical for the resolution of firearms incidents. It is recommended that where supervisors are not available immediately, a nominated team leader should act as Bronze on at least a temporary basis, so that there is a nominated Firearms Bronze Commander at all times in every firearms incident.

Recommendation 17: Chief Officers should be aware of cultural issues that may have an adverse impact on the professionalism of firearms units and address them effectively.

Recommendation 18: Chief Officers should ensure that, if firearms officers commonly use nicknames in their operational work, these names do not have offensive meanings or connotations and that use of offensive nicknames is regarded as discreditable conduct.

AVAILABILITY AND USE OF LESS LETHAL OPTIONS AND EXISTING ALTERNATIVE TACTICS

Recommendation 19: It is recommended that Gold and Silver Commanders should be able to demonstrate rigour in their decision taking, and the adequacy and consistency of the recording of this information should be evaluated by each force and reviewed by the Chief Officer. It is further recommended that only duty inspectors who have completed the firearms command course should adopt the Firearms Silver Command role.

Recommendation 20: It is recommended that control room staff receive appropriate training to enable them to provide prompts to officers attending incidents, seek standard information on behalf of the armed officers and initiate the provision of supporting resources for officers attending the scene. Only officers who have received appropriate training in the management of firearms incidents should be involved in this critical role within the control room.

Recommendation 21: ACPO should review the methods used for recording the booking out of weapons, ammunition and other firearms equipment.

Police Complaints Authority 119 CONTAINMENT AND THE SPEED OF RESOLUTION

Recommendation 22: The Commissioner of the Metropolitan Police Service, the Metropolitan Police Authority and the Home Office should jointly commission a review of tactical options in the MPS including a data-based research study investigating the relationship between firearms tactics and outcomes in the MPS. The research component of the review, which should be undertaken as soon as possible, should have the following terms of reference:

1. A systematic analysis of firearms deployments in the MPS between 1998 and 2001, including data on reason for the operation, resources deployed, resources utilised, incident outcome and subsequent events (eg disciplinary action resulting). 2. The review should examine any differences in any of the above factors as a consequence of the location of the shooting and the characteristics of the suspect (including ethnic status but focusing on vulnerability resulting from substance use or mental health issues). 3. An analysis of the data collection procedures used within SO19, the accuracy of data returns to HMIC and methods of dissemination for lessons to be learned and for identifying ‘near misses’ and learning from them. 4. The review should a) reach conclusions on the lessons to be learned, b) make appropriate recommendations for future policy and practice and c) be published.

CHARACTERISTICS OF THE INDIVIDUAL SHOT

Recommendation 23: It is recommended that a review is conducted by The Police Skills and Standards Organisation to establish the standards required for armed officers to be considered competent, and that the implementation of standards should be subject to periodic review by HMIC.

Recommendation 24: It is recommended that the requirement to record accurately training records should be a duty on instructors and training managers, and failure should be considered a discipline offence. This process should be overseen by the Chief Officer and subject to scrutiny by the police authority.

Recommendation 25: It is recommended that Chief Officers ensure that when an ARV is deployed immediate consideration is given to the dispatch of an appropriately trained police dog and handler. ACPO should consider the development of a joint training package for firearms units and police dog handlers.

120 Police Complaints Authority Recommendation 26: Chief Officers should, as a matter of urgency, review the operational rationale for the use of police dogs in firearms incidents and consider the training and development issues that will result from such a review. Consideration should be given to the use of passive attack dogs in firearms operations even if, as a result of resource concerns, they have to be shared by several forces. This process should be overseen by ACPO.

Recommendation 27: It is recommended that protocols for unarmed containment are reviewed by Chief Officers, and this review should examine the training of unarmed officers in placing containments.

Recommendation 28: The ACPO Firearms Manual should be amended to provide clear guidance for the containment and management of individuals who are armed and ignoring police instructions, as a function of indifference about whether they are shot.

Recommendation 29: It is recommended that the response of police, health service and other agencies to people in mental health crisis that appear to be posing a threat to life is reviewed by Government. A working group involving the Home Office, the Department of Health, ACPO and relevant NGOs should be convened to address this issue.

Recommendation 30: It is recommended that the review proposed above examines how intelligence and information are used by armed and other officers dealing with a person in mental crisis apparently posing a threat to life, particularly around use of information and support from family members and carers.

Recommendation 31: It is recommended that the training which firearms officers receive in mental health awareness issues should be reviewed to ensure that emphasis is placed on the recognition of irrational behaviour and its possible causes and that this recognition be used in the development of tactics for the management of the incident. This amendment to training content should be developed by each Chief Officer and overseen by the Police Training and Development Board.

Recommendation 32: ACPO should ensure that protocols for inter-agency agreements with local addiction and mental health services are developed to ensure that joint working arrangements can be reached for the identification of at-risk populations, and for the joint training of firearms officers and health professionals. The review of mental health issues proposed above include attempts at identifying and promulgating ‘good practice’ around the management of mental health related firearms incidents, and this should form the basis for the development of national standards.

Recommendation 33: It is recommended that ACPO, the PCA, the CPS and Coroners, in the light of this review, examine their practice and procedures with a view to minimising delays without compromising the rigour and depth of scrutiny and investigation required in supervised investigations into shootings which cause death or injury.

Police Complaints Authority 121 Recommendation 34: It is recommended that families are made aware by the PCA supervising member of who to contact to receive help and advice about the provision of legal advice and support. It is recommended that the PCA revises its leaflet to provide more information for bereaved families explaining issues around who to contact for legal advice and other support as an interim measure, prior to the creation of the IPCC.

Recommendation 35: It is recommended that forces should consider in advance a policy in relation to requests for them to meet funeral costs. ACPO and the APA should seek to promote jointly national guidelines to ensure that there is consistency on this issue across forces, so that whether funeral expenses are paid does not depend simply on where the victim was shot.

Recommendation 36: It is recommended that ACPO, after consultation with police staff associations, revise the Firearms Manual guidance on the making of notes by principal officer(s) to limit the circumstances where notes are not required to be made only to where there is either clear evidence of medical unfitness to make notes or, for sound investigative reasons, the officer is not asked to do so. Officers other than principal officers should always be expected to complete notes if fit for continued duty. The manual should emphasise that there is a presumption that police officers are expected to assist in the search for the truth.

Recommendation 37: It is recommended that the Home Office introduce as soon as possible regulations to change the disciplinary caution so as to encourage police officers to co-operate with investigations.

Recommendation 38: Supervisory officers should ensure, in management of staff post-incident, that officers comply with ACPO guidelines. (See para. 2.60)

Recommendation 39: It is recommended that the PCA should agree with ACPO and HMIC criteria for the selection of SIOs for shootings by police and should consider the establishment of a cadre of specialist firearms SIOs.

Recommendation 40: It is recommended that the PCA supervising member, having discussed this matter with the SIO, discusses with the family any personal knowledge the investigators may have of officers involved in the case and how decisions on the selection of investigators are documented to try to increase the confidence of the family in the investigation.

Recommendation 41: It is recommended that a standard style for Senior Investigators’ reports should be consistent with the format and style recommended in the PCA Supervision Manual.

122 Police Complaints Authority Recommendation 42: It is recommended that an internal SIO obtains independent advice on the actions of armed officers, the command, tactical advice, training and policy in relation to the police use of firearms from someone with relevant experience of such incidents. Similarly, where ‘expert’ advice is cited by investigators, the use of the term ‘expert’ should be supported by evidence of both professional qualification and relevant experience.

Recommendation 43: It is recommended that the family or their representative are advised what will be disclosed to them and when, and that a general approach of openness should be adopted as long as it is consistent with issues of witness safety, legal requirements and public interest. The Police Reform Act 2002 makes provision for the disclosure by investigators of information to complainants and next of kin and detailed regulations will supplement the new duties placed on the IPCC and the police service.

Recommendation 44: The PCA should review its role in supervising family liaison in shooting incidents prior to the creation of the IPCC. It should consider the appointment of external family liaison to supplement or replace the police FLO in exceptional circumstances, as envisaged in the Family Liaison Strategy produced in 2000 by the ACPO Homicide Working Group on behalf of the Crime Committee. Clear protocols would be required establishing the relationship between the FLO and the SIO to ensure that the FLO was kept informed about progress in the investigation.

Recommendation 45: The PCA should review its co-ordinating and central liaison role with family members through each stage of the investigation process up to and beyond the coroner’s inquest, and should also review its role in liaising between the different agencies involved in the post-incident period, prior to the creation of the IPCC.

Recommendation 46: It is recommended that the information that is given to all families about disciplinary proceedings involving police officers is reviewed by the PCA and ACPO.

Recommendation 47: Recommendations made following an investigation should be passed to the Police Skills and Standards Organisation, to the APA for dissemination to relevant police authorities and to the “Learning the Lessons from Adverse Incidents” Committee.

Recommendation 48: It is recommended that recommendations made after an investigation should be passed to the investigator of any future incident by the PCA for their information, and to be included in the terms of reference where applicable.

Police Complaints Authority 123 Appendix 2: Standardised pro forma used for analysis of PCA case files

Pro Forma for the Recording of Police Discharges of Firearms

Rater: Date:

Section 1: Background characteristics

PCA file reference no: ......

Date of shooting: ......

Name of person shot (if applicable): ......

Location of shooting (Town/city): ......

Home Force involved: ......

Investigating Officer: ......

IO’s Force: ......

PCA Supervising Member: ......

Section 2: Basic characteristics of the event

Number of suspects/victims involved: ......

Number of suspects/victims shot: ......

Classification of the Event:

ROBBERY DOMESTIC OTHER

Was the shooting:

INDOORS OUTDOORS OTHER (explain)

Level of light at the start of the incident:

NO LIGHT NATURAL LIGHT ARTIFICIAL LIGHT TORCHLIGHT

Comment: ......

124 Police Complaints Authority Changes in light conditions over the course of the incident:

Comment: ......

Weather conditions:

CLEAR RAINY FOGGY OTHER

(Describe) ......

NOT RELEVANT

Changes in weather conditions over the course of the event:

Comment: ......

Was the operation:

PRE-PLANNED SPONTANEOUS COMBINATION (Describe) ......

......

Section 3: Brief description of the event

Police Complaints Authority 125 Section 4: Characteristics of suspect/victim #1 shot

Name: ......

Age: ......

Sex: MALE FEMALE

Ethnicity: ......

Did he/she speak English well enough to be understood by officer?

YES NO

Was the person known to be intoxicated at the time of the shooting?

YES NO

If so, with what? ......

Was the person known to have a history of addiction problems?

YES NO

If so, when did this become known to the police? ......

Was the person known to have a history of mental health problems?

YES NO

If so, nature of the problem: ......

When did this become known to the police? ......

Previous criminal convictions?

YES NO

If so, when did they become known to police:......

Nature of injuries sustained: were the injuries fatal:

YES NO

Location of injuries ......

Severity ......

Type of suspect/victim’s weapon: ......

126 Police Complaints Authority Was the weapon real:

YES NO

Was the weapon loaded:

YES NO

Did the suspect know how to use it:

YES NO UNKNOWN

Did the offender intend to use it:

YES NO UNKNOWN

Was it used:

YES NO

If so, when and how often: ......

Was the weapon ever aimed at anyone:

YES, Before Firearms Officers arrived

YES, After Firearms Officers arrived

NO

Other relevant characteristics of the suspect/victim:

Section 5: Characteristics of suspect/victim #2

Name: ......

Age: ......

Ethnicity:......

Did he/she speak English well enough to be understood by officer?

YES NO

Was the person known to be intoxicated?

YES NO

If so, with what? ......

Was the person known to have a history of addiction problems?

YES NO

If so, when did this become known to the police?......

Police Complaints Authority 127 Was the person known to have a history of mental health problems?

YES NO

If so, nature of the problem: ......

When did this become known to the police? ......

Was the person armed?:

YES NO

If yes, details of weapon and use:......

Previous criminal convictions: ......

Nature of injuries sustained:......

Other relevant characteristics of the suspect/victim: ......

Section 6: Characteristics of suspect/victim #3

Name: ......

Age: ......

Ethnicity: ......

Did he/she speak English well enough to be understood by the officers?

YES NO

Was the person known to be intoxicated?

YES NO

If so, with what? ......

Was the person known to have a history of addiction problems?

YES NO

If so, when did this become known to the police? ......

Was the person known to have a history of mental health problems?

YES NO

128 Police Complaints Authority If so, nature of the problem: ......

When did this become known to the police? ......

Was the person armed?:

YES NO

If yes, details of weapon and use: ......

Previous criminal convictions: ......

Nature of injuries sustained: ......

Other relevant characteristics of the suspect/victim: ......

Section 7: Other injuries and intelligence

(please insert in each box the nature of the injuries and how they were caused)

Before the After the arrival of firearms firearms officers had officers arrived

Injuries to officers

Injuries to members of the public

Injuries to victim/suspect

Police intelligence

Date/Time Reason

Most recent police contact of suspects/victims

Intelligence available

Contact with other relevant agencies

Police Complaints Authority 129 Note taking and recording

Did officers record their actions in notebooks?

YES NO

If so, when (date and time)?......

Did this happen after a group de-brief?

YES NO

Were officers able to collaborate with colleagues before any de-brief?

YES NO

If so, what form did this take? ......

Section 8: Characteristics of officer #1 who discharged their weapon

Rank: ......

Force: ......

Team: ......

ARV YES NO

SFU* YES NO

Sex: MALE FEMALE

Ethnicity: ......

Age:......

Length of time in police: ...... years

Was he/she:

Authorised firearm officer:

YES NO

Specialist firearm officer:

YES NO

Length of time in current post: ......

Length of time as firearms trained: ......

*Specialist Firearms Unit

130 Police Complaints Authority Has the officer fired 3 classification shoots in last 12 months:

YES NO

Level of training achieved: ......

Date of last training and nature of training:......

Was officer blood tested after event:

YES NO

If so, outcome: ......

Was the officer briefed:

YES NO

If so, how? ......

When? ......

Was the officer de-briefed:

YES NO

If so, how? ......

When?......

Was the officer:

TEMPORARILY REMOVED FROM OPERATIONAL DUTY YES NO

SUSPENDED FROM THE FORCE YES NO

Length of time on duty that day at start of incident: ......

Previous involvement in shootings? (1)......

(2) ......

What was the officer wearing?......

Weapon used? ......

Other weapons available? ......

Reason for choice of weapons? ......

Number of rounds fired:

Weapon 1 (Specify) ......

Weapon 2 (Specify) ......

Other relevant characteristics ......

Police Complaints Authority 131 Section 9: Characteristics of officer #2 who discharged their weapon

Rank: ......

Force: ......

Team: ......

ARV YES NO

SFU YES NO

Sex: MALE FEMALE

Ethnicity:......

Age: ......

Length of time in police: ...... years

Was he/she:

Authorised firearm officer: YES NO

Specialist firearm officer: YES NO

Length of time in current post: ......

Length of time as firearms trained: ......

Has the officer fired 3 classification shoots in last 12 months:

YES NO

Level of training achieved: ......

Date of last training and nature of training: ......

Was officer blood tested after event:

YES NO

If so, outcome: ......

Was the officer briefed:

YES NO

If so, how? ......

When?......

132 Police Complaints Authority Was the officer de-briefed:

YES NO

If so, how? ......

When? ......

Was the officer:

TEMPORARILY REMOVED FROM OPERATIONAL DUTY YES NO

SUSPENDED FROM THE FORCE YES NO

If yes, how long were they suspended for? ......

Length of time on duty that day at start of incident: ......

Previous involvement in shootings? (1)......

(2) ......

What was the officer wearing? ......

Weapon used? ......

Other weapons available? ......

Reason for choice of weapons? ......

Number of rounds fired:

Weapon 1 (Specify) ......

Weapon 2 (specify) ......

Other relevant characteristics ......

Section 10: Characteristics of Silver Commander (REPLICATE THIS TABLE IF MORE THAN ONE SILVER COMMANDER INVOLVED)

Name......

Rank:......

Force: ......

Team: ......

Sex: ......

Age: ......

Police Complaints Authority 133 Length of time in police: ...... years

Length of time in current post: ......

Length of time as firearms trained: ......

Level of training achieved: ......

Length of time as firearms incidents manager: ......

Level of training achieved: ......

Date of last training and nature of training: ......

How did officer receive information: _......

When was this information received? ......

Did Silver commander adhere to force policy? ......

YES NO

If not, why not? ......

When was Gold Command informed? ......

How was the officer de-briefed? ......

Length of time on duty that day at start of incident: ......

Any history of previous involvement in shootings?

YES NO

If yes, give details: ......

Frequency of risk assessment:......

Resources deployed: ......

Frequency of communication with officers: ......

Frequency of communication with Gold Command: ......

Frequency of communication with Bronze Commanders: ......

Was there any evidence that the officers involved were dissatisfied with the command structure?

YES NO

Was there any evidence of adverse effects on morale of the management of the incident?

YES NO

134 Police Complaints Authority Section 11: Characteristics of Gold Commander

Name:......

Rank: ......

Force: ......

Team: ......

Sex: ......

Age: ......

Length of time in police: ...... years

Length of time in current post: ......

Length of time as firearms trained: ......

Level of training achieved: ......

Length of time as firearms incidents manager: ......

Level of training achieved: ......

Date of last training and nature of training: ......

How did officer receive information: ......

When was this information received? ......

Were instructions given to Silver Command? ......

If so what? ...... _

Any history of previous involvement in shootings?

YES NO

If yes, give details: ......

Actual involvement in the incident: ......

Frequency of communication with Silver Command: ......

Police Complaints Authority 135 Section 12: Overall supervision of the incident

Command structure

When was this established? ......

Who made this decision? ......

How did it change over the course of the incident? ......

Incident plan

Brief description......

......

When was it established? ......

Did it change over the course of the incident and why? ......

Incident log

Who kept this? ......

When was it established? ......

Was it complete and accurate?

YES NO

Comments on overall supervision:......

Was tactical advice requested

YES NO

Was tactical advice available

YES NO

Was tactical advice received

YES NO

Comments on tactical advice

Was the Silver Commander trained to deal with the incident

YES NO

Comments: ......

136 Police Complaints Authority Was the Gold Commander trained to deal with the incident

YES NO

Comments: ......

Were suitable resources available to deal with the incident

YES NO

Comments: ......

Were the resources available adequately deployed

YES NO

Comments: ......

How many ARV’s were involved? ......

How many armed officers were involved in total: ......

Were there sufficient firearms officers involved:

YES NO

Were dogs deployed:

YES NO

Comments: ......

Section 13: Weapon discharged

Type of weapon:

Discharge of rounds

NUMBER TIME TYPE DISTANCE IMPACT (?) COMMENT 1

1

2

3

4

5

Police Complaints Authority 137 Over-penetration:

YES NO

Comments: ......

Was the weapon used suitable for UK police service

YES NO

Comments: ......

Was the ammunition used recommended as suitable for UK police service

YES NO

Comments: ......

What ammunition was used:

Maker: ......

Calibre: ......

Weight: ......

Construction: ......

Were the officers deployed safely:

YES NO

Comments: ......

Was the area successfully contained:

YES NO

Comments: ......

138 Police Complaints Authority Section 14: Involvement of the family/ community groups

Time to inform family: ......

Date of initial IO contact: ......

Frequency of IO contact with family by:

Meeting ......

Letter ......

Telephone ......

Date of initial PCA contact: ......

Frequency of PCA contact with family by:

Meeting ......

Letter ......

Telephone ......

Was a complaint made: ......

Outcome of complaint: ......

Was an FLO used:

YES NO

If so, was this acceptable to the family?

YES NO

Was frequency of FLO contact with the family satisfactory?:

YES NO

Description of family response ......

Description of other forms of community liaison ......

Police Complaints Authority 139 Section 15: CPS/PCA involvement

Date of referral to CPS: ......

Date of CPS decision: ......

Nature of CPS decision: ......

Date case referred back to PCA from the CPS:......

PCA supervising member: ......

Date of PCA interim statement: ......

Date of PCA decision: ......

PCA charges against officers: ......

Was case completed within 120 days:

YES NO days to completion:......

PCA recommendation to Force: ......

Section 16: Coroners court

Was there a coroners inquest?

YES NO

IF yes, date: ......

Verdict: ......

Recommendations: ......

Comment: ......

140 Police Complaints Authority Section 17: IO recommendations

Yes No N/A

IO did not hold the individuals officers culpable

IO found the incident management to be unsatisfactory

IO found fault with the Silver Commander

IO found fault with the Gold Commander

IO did not recommend disciplinary charges

IO Recommendations

1......

2......

3......

Was there a criminal hearing?

YES NO

If yes, outcome:...... _

How adequate was the post-incident management in terms of:

Debriefing:

GOOD ADEQUATE POOR

Comment: ......

Evidence collection:

GOOD ADEQUATE POOR

Comment: ......

Officer welfare:

GOOD ADEQUATE POOR

Comment: ......

Police Complaints Authority 141 PCA Re iwo shootings from 1998 to 2001 view of

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